My Facebook friend Jim, a 60-year-old bus driver, has gained weight recently. His body-mass index (BMI) is up to 36 and his HbA1c is 7.4%. Under new guidelines approved by the ADA, his doctor advised him to have diabetes surgery. Should he? Should you? How do you decide?
What is diabetes surgery?
Diabetes surgeries, also called “metabolic surgeries,” are more often called “weight-loss” or “bariatric” surgeries. It’s a group of operations that reduce the amount you can eat, limit how much of the food you eat is absorbed, or both.
Recently, I described the four main procedures used.
• Sleeve gastrectomy (SG) removes most of the stomach. Adjustable gastric banding (AGB) creates a pouch at the top of the stomach so that little food can be taken at a time. These are called “restrictive procedures.”
• Duodenal switch (DS) rearranges the intestines so that much less food can be eaten and absorbed. Gastric bypass (GBP) restricts the stomach to the size of an egg, and also restructures the intestine so less food is absorbed. These procedures are both restrictive and malabsorptive.
All these procedures frequently cause Type 2 diabetes remission, meaning HbA1c comes down to 6% or less without use of medications. People who have had diabetes longer and those who have worse control are less likely to go into remission, but nearly everyone sees significant improvement.
How can surgeries help diabetes?
These procedures were developed to help extremely heavy people lose weight. It was a great surprise when patients starting reporting that their diabetes got better after surgery.
Why this happens is not fully understood. Weight loss doesn’t explain the diabetes remission. Surgery patients often have vastly improved, even normal, glucose numbers right after surgery, before weight is lost.
Some of this improvement may be due to hormonal changes in the restructured gut. Among other changes, gastric bypass recipients have higher levels of the incretin hormone GLP-1, and lower levels of the hunger hormone ghrelin.
However, Dr. Roy Taylor of Newcastle University (UK) says the hormones play only a minor role. He says, “Acute negative calorie balance [eating very little] is all that is needed to reverse Type 2 diabetes.”
Dr. Taylor has provided evidence for this with his 600-calorie-a-day diet experiments we reported on here and here. According to Taylor, anyone who can follow his super-strict diet for roughly eight weeks is likely to turn off their diabetes. Then if they can stay on a somewhat looser but still restricted diet — say, 1200 calories a day — their diabetes will stay in remission.
Almost certainly, both factors — limited eating and hormonal changes — are involved in diabetes remission.
Side effects of surgery
If my friend Jim can reverse his diabetes without surgery, he could save himself a lot of trouble. Negative effects of surgery can range from embarrassing to fatal.
In The Huffington Post, Senior Editor Sarah Klein reported that both men and women experience incontinence of urine and/or feces after surgery. Many experience nausea and vomiting. Patients have to learn to eat small bites slowly, chew for a long time, and avoid many foods to avoid vomiting, cramping or diarrhea.
More than a third of metabolic surgery patients develop gallstones. Many gastric bypass patients may develop gastric ulcers where the stomach dumps into the intestine. Some get extreme low blood sugars after meals.
About 20% of weight-loss surgery patients require further procedures to revise the new connections, shrink or stretch the stomach pouch, or address complications, according to WebMD. Malnutrition-related complications, mainly anemia and osteoporosis (thinning bones), may affect almost 30% of metabolic surgery patients.
According to The Huffington Post, “Patients are also at risk for dehydration, since the stomach can no longer hold large quantities of water.”
Although many studies show that weight-loss surgery patients report a higher quality of life, certainly many patients do not. Some suffer fatigue, coldness, hair loss, depression, and irritability. Some research has found that weight-loss surgery patients commit suicide at a 50% higher rate than nonsurgical patients.
Patients’ relationship with food changes dramatically. Since you have to be careful with every single bite, it’s hard to eat for pleasure or comfort. Some turn to drugs or alcohol as a replacement. A survey by psychologist Dr. Alexis Conason of the New York Obesity Nutrition Research Center found that surgery patients had a 50% increase in frequency of substance abuse two years after their operations.
Weight regain, diabetes return
Usually, weight is lost for the first 18 months after surgery, and glucose control greatly improves. Then weight loss stops, and at two years out, weight often starts to be regained.
The stomach pouch may stretch to allow more food. People often substitute “soft calories,” meaning sugars, for healthier food. Hormone secretion may change over time.
Diabetes can also relapse. An analysis in the journal Obesity Surgery found that, while many patients will experience remission of their diabetes with surgery, the average remission lasts 8.3 years. About one-third of patients experience a relapse within five years of remission.
A Swedish study with 18-year follow-up found that 72.3% of diabetes surgery patients were in remission after two years. At 15 years, only 30% were still diabetes-free.
Effects on health and death rates
How does diabetes surgery affect your risk of death or serious complications? In the Swedish study, the surgical patients had about half as many nerve, eye, and kidney complications and one-third less heart disease than the control group, who treated their diabetes medically.
Heavy people who have metabolic surgery have lower death rates from disease than matched controls who don’t have surgery. A study in Utah followed thousands of obese patients for roughly 15 years. Those who had surgery had about 50% less death from all types of diseases studied in the trial.
However, the surgical patients had much higher rates of death from non-disease causes such as suicide, accidents, and drug abuse. For death from all causes, the surgical group had about a 30% lower risk than the control group.
How do you decide?
The pros of diabetes surgery are that your diabetes will likely get much better or disappear, at least for a while. So will your high cholesterol. You will lose a lot of weight.
The downsides include the risks, discomfort and expense of surgery, the possibility of serious physical and psychological side effects, and the probability that weight and diabetes will return over the long term.
The loss of food as a comforter and friend and the constant worries about eating are also serious downsides. But many people with diabetes already have a problematic relationship with food.
Of the four procedures, all cause weight loss, but gastric bypass or duodenal switch are most effective in treating diabetes. They also appear to have more risks and side effects and cost more.
In theory, you could get most of the benefits of surgery through self-management, without the risks and pain. You can look at some ways to do that in this article on reversing Type 2 diabetes, or many other articles and books you can find on the Web.
But you might be like my friend Jim who believes he can’t control his emotional eating without surgical help. I strongly advised him not to have it, but it’s his decision. For your body, the choice is yours.
Are you thinking about metabolic surgery? Have you already had it? Please share your thoughts and experiences by commenting here. You may help someone in a similar situation.