Bariatric Surgery Endorse Recommendations
For the first time, metabolic surgery is 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 45 international professional organizations including the American Diabetes Association (ADA), the International Diabetes Federation (IDF), the American Society for Metabolic and Bariatric Surgery (ASMBS).
The guidelines emerged from the 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference held last last fall in London and jointly organized with the ADA, IDF, Diabetes UK (DUK), Chinese Diabetes Society (CDS), and Diabetes India (DI). According to the authors, “the report from DSS-II in Diabetes Care reflects the most comprehensive and rigorous assessment of the available evidence on the subject to date, provides a thorough analysis of current knowledge gaps in the field, and identifies priorities for research designed to further refine the role of surgery in the diabetes management algorithm.”
Dr. David Cummings, an endocrinologist at the University of Washington and senior author of the guidelines told the Associated Press, “We do not claim that surgery should be the first-line therapy,” but as standard care often isn’t enough, “it’s time for something new.”
According to the new guidelines, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40), as well as in those with Class II obesity (BMI between 35 and 39.9) if hyperglycemia is
Philip Schauer, MD
Dr. Philip Schauer, MD, of Cleveland Clinic and past president of the ASMBS, who has been a leading researcher and proponent of metabolic surgery, said these new guidelines are important because it gives doctors a powerful tool when treating patients with type 2 diabetes who are not responding well to conventional
“This is a safe and effective operation and I think the consensus of the medical community is finally catching up with the science,” said Dr. Schauer.
On August 15, 2007, the American Society for Bariatric Surgery formally changed its name to the American Society for Metabolic and Bariatric Surgery to reflect the mounting clinical evidence back then demonstrating the effectiveness of surgery on metabolic disease particularly
type 2 diabetes.
Raul Rosenthal, MD
“Maybe we were a little ahead of our time back then,” said Raul J. Rosenthal, MD, president, ASMBS. “But nine years and a mountain of data later, we are in a position to help a lot more people. And that’s what this is all about – helping people live better and longer lives.”
The conclusions found in the new guidelines and recommendations are based on a large body of evidence including 11 randomized clinical trials showing that in most cases, surgery can either reduce blood sugar levels below diabetic thresholds (“diabetes remission”) or maintain adequate glycemic control despite major reduction in medication usage. The article states that while relapse of hyperglycemia may occur in up to 50 percent of patients with initial remission, most patients maintain substantial improvement of A1c over the long term.
Franceso Rubino, MD
“Surgery represents a radical departure from conventional approaches to diabetes. The new Guidelines effectively introduce, both conceptually and practically, one of the biggest changes for diabetes care in modern times,” said Dr. Franceso Rubino, a Professor of Metabolic and Bariatric Surgery at King’s College London in the UK, co-director of the DSS-II and the first author of the report, said in an ADA news release. “This change is supported by documented clinical efficacy and by the evidence of an important role of the gut in metabolic regulation, which makes it an appropriate target for anti-diabetes interventions,” Dr. Rubino added.
Dr. Rubino also wrote commentary in the journal Nature, where he reflected on how the medical community has changed its thinking about surgery and diabetes, but that even more change is necessary. “I have witnessed first-hand how getting to this point has required many clinical scientists to put aside long-standing preconceptions. Indeed, the guidelines come nearly 100 years after the first clinical observations that diabetes could be improved or even resolved by a surgical operation. The evidence that surgery can prompt the remission of a disease that has long been considered irreversible could bolster searches for what causes diabetes and even reinvigorate hopes to find a cure. But future progress will require more thinking outside the box.”
The guidelines come just as the Centers for Disease Control and Prevention (CDC), announced that rates of obesity in America are continuing to rise, particularly among women. For the first time, more than 40 percent of women have obesity, compared to 35 percent of men. Overall, about 38 percent of all adults have obesity, which is linked to a whole host of other diseases and conditions including diabetes. The ADA reports that in 2012, 29.1 million Americans, or 9.3 percent of the population, had diabetes, and 1.4 million Americans are diagnosed with diabetes every year.
The special issue of Diabetes Care include 10 other articles on the status of the “pandemic of diabetes” and metabolic surgery issues; the role of the gut in glucose homeostasis; the mechanisms of diabetes improvement following bariatric surgery; clinical outcomes of bariatric surgery; ethnic considerations for metabolic surgery; barriers to appropriate utilization of surgery; and reports on the potential for weight-loss surgery as a potential treatment for youth with type 2 diabetes, patients with obesity and type 1 diabetes, and those with mild obesity.