Metabolic Surgery: A Crucial Aspect of Diabetes Care

In its 2018 guidelines, the ADA elevated metabolic surgery to its Top Tier of recommendations for the treatment of type 2 diabetes. According to both the National Institutes of Health and the American Diabetes Association, bariatric surgery is recommended for all individuals with a BMI of 35 or more who have type 2 diabetes -without exceptions.

Based on research that shows remission of diabetes even among lower-BMI individuals after metabolic surgery, the ADA also recommends bariatric surgery for individuals with BMI 30-34 when medications are not fully controlling the blood sugar.

Up until recently, most cases of type 2 diabetes have been managed with diet, exercise, insulin therapy and other medications. But the American Diabetes Association (ADA) now believes there is a better and more permanent solution for people with diabetes that often replaces injectable and oral medication: metabolic surgery, also known as weight-loss surgery. More doctors are embracing the ADA’s position on metabolic surgery as a crucial aspect of diabetes care.

Numerous studies, going back decades, demonstrate that a high percentage of individuals experience complete remission or reduction in severity of their type 2 diabetes after sleeve gastrectomy, which removes 70 to 75 percent of the stomach and forms the remaining portion into a slender tube. Traditionally, sleeve gastrectomy has been used to prompt significant, sustainable weight loss by altering metabolic hormones, limiting how much food a person can eat and creating a sense of fullness faster. As patients lose weight, they often experience a resolution or elimination of obesity-related health problems, such as heart disease, stroke, high blood pressure, osteoarthritis, sleep apnea and diabetes.

How Does Metabolic Surgery Resolve Diabetes?

Laparoscopic sleeve gastrectomy is a 45-minute procedure that changes the underlying hormones that regulate blood sugar and metabolism, resulting in a “re-set” that lowers body weight and blood sugar. In addition to weight-related mechanisms, some of the identified mechanisms of action in resolving diabetes include:

  1. Increased secretion of glucagon-like peptide-1 leading to hyperinsulinemia and early normalization of glucose levels.
  2. Enhanced peripheral tissue sensitivity to insulin.
  3. β-cell sensitivity improves at 12 months and after the loss of approximately 33 percent of excess weight.

Roadblocks to Metabolic Surgery as a Primary Treatment for Diabetes

The ADA’s recommended BMI criteria are not as widely known as they might be, and many patients with diabetes are unaware that sleeve gastrectomy today is a 45-minute laparoscopy with risks on par with that of gallbladder or knee surgery. The ADA criteria are important because insurance companies, including Medicare and Medicaid, increasingly rely on them when deciding who to cover for surgery.

Currently, less than 5 percent of people that qualify based on these ADA Guidelines are actually referred for surgery.

According to Kent Sasse, M.D., MPH., director of the nationally accredited bariatric center and adjunct assistant professor of physiology and cell biology at the University of Nevada School of Medicine, “It is a wonder that so few patients with diabetes and obesity are considering metabolic surgery, when it is clearly among the most effective treatments today.”