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IDF recommends bariatric surgery for T2DM

Calls for national health services to develop guidelines for the use of gastric banding and bypass surgeries for T2DM patients
Paper finds that surgery is also effective at cutting medical costs for diabetes patients

Bariatric surgery should be considered earlier in the treatment of obese patients with type 2 diabetes mellitus, according to the International Diabetes Federation (IDF). In a position paper issued by the Federation’s Task Force on Epidemiology and Prevention, the IDF claims that the use of surgery is effective both in treating the condition and cutting medical expenditure over diabetics’ lifetime, and calls for national health services to develop guidelines for the use of gastric banding and bypass surgeries among type 2 diabetes patients.


Position paper

The paper, “Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes,” which was presented to the 2nd World Congress on Interventional Therapies for Type 2 Diabetes in New York on 28 March, describes diabetes as “one of the greatest public health threats of the 21st century”, with 438 million people expected to have the diseaseby 2030. The IDF claim that healthcare systems around the world need to respond with as powerful an arsenal of treatments as possible, and as such, bariatric surgery should be an accepted option for type 2 diabetes patients with a BMI of over 35, and a priority for those with a BMI of over 40. 


438 million people expected to have the type 2 diabetes mellitus by 2030

Blaming negative societal attitudes for the lack of provision of clinically effective and cost-effective healthcare for people with severe obesity and type 2 diabetes in the past, the Federation points to a growing body of evidence suggesting that the health of obese people with type 2 diabetes can be substantially improved by bariatric surgery under certain circumstances.


Using evidence from several studies, including the Swedish Obese Subjects Study, the paper claims that after bariatric surgery, 72% of type 2 diabetes patients who undergo surgery are in remission after two years, as opposed to 21% of patients who do not have surgery (see table 1).


Table 1: Two & 10 year diabetes incidence and remission rates from the Swedish Obese Subjects Study

Component Surgical Control
2-year incident 1% 8%
10-year incident 8% 24%
2-year remission 72% 21%
10-year remission 36% 13%

Remission based on fasting plasma glucose <7.0 mmol/l and not on hypoglycaemic therapy

Evidence suggests that earlier intervention increases the likelihood of remission, and so surgery should be considered early in the treatment, rather than as a measure of last resort.


In the UK, the National Institute for Health and Clinical Excellence recommends bariatric surgery as a treatment option for adults with a BMI of over 35 and type 2 diabetes, if non-surgical methods of treatment have been exhausted. However, the IDF claims that in countries with the highest bariatric surgery uptake, only 2% of eligible candidates are treated annually.


The paper finds that surgery is also effective at cutting medical costs for diabetes patients. The financial costs of type 2 diabetes can be severe: the lifetime cost of a patient diagnosed with diabetes in his thirties is estimated at around US$305,000, including direct medical costs, lost productivity, disability and early death.


IDF Recommendations

1. Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity (BMI equal to or greater than 35) not achieving recommended treatment targets with medical therapies, especially where there are other obesity related co-morbidities. Under some circumstances people with a BMI 30-35 should be eligible for surgery 

2. It is up to each health system to determine whether bariatric surgery with its support services is economically appropriate. 

3. Surgery should be considered as complementary to medical therapies to reduce micro-vascular and cardiovascular risk 

4. Patients should be assessed and managed by experienced multi-disciplinary teams 

5. Glycaemic control should be optimised peri-operatively and should be closely monitored after surgery 

6. On-going and long-term nutritional supplementation and support must be provided to patients after surgery 

7. Apart from conventional procedures now in use new techniques and devices should be explored in research settings only. Conventional procedures should be standardised. Other techniques, variations and novel devices can be introduced when supported by an evidence base. 

8. Procedure selection requires appropriate assessment of risk vs. benefit of each operation as part of the process for selecting the surgical treatment options for an individual patient. 

9. New bariatric procedures require robust assessment for their efficacy, safety, and durability using similar principles to those for assessing new drug therapies and having regards to the benefits and risks of established therapy. 

10. Regional surgical expertise, multidisciplinary team experience, and documented quality outcomes are important factors in the regional choice of bariatric procedures. 

11. There should be a minimal accepted data set for pre-surgery and follow-up to allow audit of clinical programmes eg. 

  • HbA1c 
  • Fasting glucose and insulin 
  • BMI 
  • Waist circumference 
  • Retinopathy status (recent eye exam) 
  • Nephropathy (eg test for microalbuminuria within previous year) 
  • Liver functions tests 
  • Lipid profile 
  • Blood pressure measurement 
  • Foot exam (recent) 
  • Documentation of medications – (glycaemia, lipids & HT) 
  • These should be used preoperatively. 
  • Fasting C peptide where available 
  • Auto- antibody status eg anti-GAD where available 

12. All longitudinal studies should include quality of life as one of the outcomes 

13. It should be recognised that a prolonged period of normalisation of glycaemic control has benefit even if there is eventual relapse. 

The paper also made recommendations for future avenues of research, including the benefits of surgery for diabetics with a BMI under 35, the long-term benefits and drawbacks of surgery, and the efficacy and safety of new surgical techniques like duodenal-jejunal bypass and ileal interposition.

The position paper was prepared by experts in diabetes and bariatric surgery, including Dr George Alberti, of Imperial College, London and Newcastle University, UK; Professor Francesco Rubino, of Weill Cornell Medical College, USA; and Professor John B. Dixon and Paul Zimmet, of the Baker IDI Heart & Diabetes Institute, Melbourne.

Evidence

Four studies listed in the paper judge surgery to be very cost-effective for type 2 diabetes patients, as compared to standard care, in terms of cost per year added to the patient’s expected life span. One Australian study concluded that surgery was actually cheaper than standard care, and added benefits to the health of the patient for the rest of their life.


While the IDF states that treatment for type 2 diabetes should be built on top of lifestyle interventions to promote dietary changes and physical activity, the group recognises that non-surgical strategies have very limited success in controlling blood glucose levels amongst the severely obese, with many patients not achieving targets. As such, they state that in these cases bariatric surgery should be considered.


Evidence suggests that more extensive surgeries that result in a higher BMI loss are also more effective at inducing a remission in diabetes. A systematic review states that bilio-pancreatic diversion, which results in an estimated excess BMI loss of 73%, induces a remission in diabetes 95% of the time, and Roux-en-Y gastric bypass, with an estimated excess BMI loss of 63%, has 80% effectiveness.


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