Two years ago, Jeanne Alford of Pacifica, California, faced a crisis with her diabetes. “Things were getting out of control. My weight was going up; my blood pressure was up; my hemoglobin A1C had hit 10. They wanted to start me on insulin. I was eating healthy and doing everything I could. Nothing was working.”
Jeanne, a communications consultant with top tech companies, decided to try something drastic. She had her stomach radically rearranged with gastric bypass (Roux-en-Y) surgery.
“The day after surgery,” she says, “I stopped all my diabetes medicines.” Her glucose numbers are still below the diabetic range without medication.
Living with the surgery hasn’t been easy. She spent a week in the hospital with a wound infection and has had side effects including evil-smelling gas. She can only eat small amounts at a time, and some favorites not at all. Still, she says, it has been worth it.
“Surgery isn’t a miracle,” she says. “It is a tool. You still have to do all the same work for management and nutrition, but it’s a really powerful tool. If you overindulge, your stomach hurts. If you eat sugary things, you may get vomiting and pain, so it kind of stops you.”
The American Diabetes Association, the International Diabetes Federation, and 45 other medical organizations now recommend gastric bypass and other metabolic surgeries for overweight people with diabetes. If that describes you, your doctor may recommend surgery as an option.
The guidelines, published in Diabetes Care, say that surgery should be “recommended for people with Class 3 obesity (BMI ≥ 40, see “What Is BMI?“) who have diabetes, regardless of their glucose control.” Doctors should also recommend surgery for patients with Class 2 obesity (BMI 35–39.9) who have poor glucose control (A1c > 7.0%). People with Class 1 obesity (BMI 30.0–34.9) and poorly controlled diabetes despite lifestyle change and medication should “consider surgery as an option.”
What is metabolic surgery?
Metabolic surgery is a class of operations that used to be called “weight-loss” or “bariatric” surgery. There are several types, but the main ones used for diabetes are the Roux-en-Y gastric bypass and a partial stomach amputation called sleeve gastrectomy.
Raul Rosenthal, MD, of Cleveland Clinic Florida and president of the American Society for Metabolic and Bariatric Surgery (ASMBS), says that major studies such as Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) show that “Bypass and gastrectomy can both put diabetes into remission.” Remission means a person’s glucose has returned to normal without medication. “In the STAMPEDE trial,” he reports, “80% of bypass and 67% of gastrectomy patients went into remission of their diabetes.”
In a gastric bypass, a small pouch of stomach (about one ounce, or the size of an egg) is separated from the rest of the stomach and plugged into the middle of the small intestine. You can eat only very small amounts at a time, and what you do eat will not be totally absorbed.
Bypass also changes your intestinal hormones. After the surgery, food has a shorter distance to travel. More of it gets to the part of the small intestine that produces incretin hormones such as GLP-1, the hormone mimicked by diabetes drugs such as Byetta. Incretins stimulate insulin production and reduce insulin resistance.
In a sleeve gastrectomy, about two-thirds of the stomach — the deep part, called the “fundus” — is removed. The remaining stomach is sewed into a sleeve shape. After the surgery, one must eat smaller amounts, but absorption should remain normal.
Gastrectomy also has hormonal effects. “The stomach is a very interesting organ,” says Dr. Rosenthal, “some of which we don’t understand completely. The part that gets removed [during] a sleeve gastrectomy produces 80% of the hunger hormone ghrelin. Because of this, sleeve gastrectomy not only creates restriction but it also takes away the appetite.”
A third weight-loss surgery, the adjustable gastric band, wraps a tight band around the stomach to limit how much you can eat. It is effective for weight loss and has the advantage of being reversible, but Dr. Rosenthal says it is “rarely used for diabetes now, because it doesn’t have the hormonal effects.”
How do the surgeries work?
Gastric bypass was developed to help severely overweight people lose weight. Patients were delighted when their glucose numbers returned to normal levels, enabling them to stop taking diabetes medications.
Controversy surrounds the mechanism of action behind this dramatic improvement. Weight loss does not account for it because glucose values often return to normal within days, long before significant weight is lost.
Doctors such as Raul Rosenthal think much of the diabetes healing comes from hormonal changes and secondarily from reduction of body fat, which may contribute to insulin resistance. Dr. Roy Taylor of Newcastle University in England says that reducing fat in the liver and pancreas through restricted eating restores insulin function. This, he says, is what occurs after metabolic surgery.
Others like nutritionist Laurie Klipfel, CDE, doubt that diabetes is cured at all. Instead, they contend that the body, which could not handle normal food intake, has enough insulin to handle the far smaller amounts eaten after surgery.
In a number of long-term studies, patients who underwent surgery had lower death rates from heart disease, stroke, kidney failure, and all medical causes than patients of comparable starting weights who did not undergo surgery. They also had less sleep apnea and lost far more weight, but they had higher rates of non-medical causes of death such as accidents and suicide.
Risks and downsides
Not all doctors are sold on the value of metabolic surgery. Dr. Nick Yphantides, chief medical officer of San Diego County in California, says, “I’ve interacted with hundreds of people who have had surgery and it hasn’t worked out for them.”
The surgery does entail risks. About 1 in 200 (0.5%) patients dies, which Dr. Rosenthal says is about the same rate as for gallbladder removal. According to Dr. Yphantides, “There have also been cases of patients dying after binge eating and rupturing their staples.”
Another uncommon but serious complication is leaking from the sites where the stomach and intestines have been sutured or stapled. This can allow undigested food directly into the abdomen, leading to raging infections. A 2006 paper from Cleveland Clinic reported such infections occur in up to 4% of surgeries and can be fatal up to 30% of the time.
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.
These risks may have decreased since 2006 because surgeons and techniques have improved, but they underscore the need to have surgery performed by experienced surgeons at a skilled surgical center.
In addition to short-term risks, these types of surgery also hold the potential for longer-term downsides.
Nutrient deficiency. Since food bypasses certain key parts of the small intestine, some nutrients will not be absorbed well. Nutrient deficiencies can lead to anemia, osteoporosis, and other diseases. Dr. Rosenthal says this is very rare in practice and can be prevented with calcium and iron supplements.
Shelley Bond, owner of the jewelry website Beadjoux, had a bypass in 2003. She says, “I’m right on the border of anemic and can’t seem to get higher. I’m diligent about taking iron. You have to take it every day, but my doctor says most of the iron isn’t being absorbed.”
Vomiting and diarrhea. Bond has also experienced the side effect called “dumping syndrome.” Rapid emptying of the stomach’s contents into the intestines can cause nausea, cramps, weakness, sweating, diarrhea, and lightheadedness. Some patients also develop fecal or urinary incontinence after surgery.
Marginal ulcers. After bypass, the stomach empties into the jejunum, a part in the middle of the small intestine not protected from stomach acid. As a result, ulcers can form at the site where the stomach empties.
Addiction and depression. Many people are emotional eaters to some degree, turning to food when they are sad, stressed, or even happy. If surgery takes that option away, some will take up another vice, perhaps alcohol or drugs. A survey by psychologist Dr. Alexis Conason of the New York Obesity Nutrition Research Center found a 50% increase in frequency of substance abuse in patients two years after their operation.
Surgical patients sometimes become depressed. A Canadian study reported a 50% increase in attempted suicide in bariatric surgery patients compared to those who did not have surgery.
However, many surgical patients, like Alford and Bond, say they can still eat for pleasure, “just not as much.” Neither has had a problem with substance abuse. In fact, Alford says that her decreased food intake has lowered her tolerance for alcohol. “My friends love me because I am always able to drive them home.”
Gallstones. Up to a third of metabolic surgery patients develop gallstones, which can occur with any drastic weight loss.
Pregnancy problems. It’s probably best not to get pregnant within two to three years of metabolic surgery. New research from the University of Washington Medical Center in Seattle found that “Compared to infants of mothers who didn’t have weight-loss surgery, infants born to mothers who did were at higher risk for prematurity [8.6% versus 14%], neonatal ICU admission [11% versus 15%], and being underweight [8.9% versus 13%].
Children were more likely to be born small or premature in the first two years after surgery. After four years, the risks appeared to return to normal.
Diabetes can return. 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 relapse within five years. A Swedish study with an 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 free of diabetes.
Lost weight can also return. Patients typically lose 75% of their excess weight in the first 18 months after surgery, but then regain much of that over the next five to 10 years.
Life after surgery
Like life with diabetes, life after metabolic surgery requires self-management. Eating habits must change radically. “For my first meal, they gave me half a popsicle,” says Shelley Bond. “I was stuffed beyond belief. I couldn’t eat much for several weeks, and then it eased up.”
Although the pouch stretches with time, surgery patients cannot go back to their old ways of eating. “You don’t drink and eat at the same time,” says Jeanne Alford. “I can’t drink soda because of the fizz. No popcorn. But I don’t need that. I can go out with a friend and eat sushi and teriyaki. I can eat salads and pizza, apples and mandarin oranges. Protein shakes. Small amounts. A lot of protein and fiber.”
She doesn’t miss emotional eating at all. “Food doesn’t manage my emotions anymore,” she says. “I take the dogs for a walk, work on the computer, watch TV, call a friend, listen to jazz, meditate, get into a flow.”
Some patients become depressed after surgery, but others feel much better about themselves. Alford enthuses, “I have a lot more energy, so my outlook is brighter. Once you begin to take control back, you can start to take other steps.”
Good surgery centers make support groups available to their patients. These can help with emotional coping and practical management through information and bonding.
Deciding and preparing
Diabetes surgery is a huge decision, and you can’t reverse it. Some people, including patients of Dr. Taylor, many Diabetes Self-Management readers, and Dr. Yphantides himself attain diabetes remission without surgery. For others, surgery presents a powerful although difficult tool to aid self-management.
“First, try a nonsurgical approach, diet, lifestyle,” says Dr. Rosenthal. “When it becomes very difficult to get control even with medicines, consider surgical approaches.”
You will have to choose between bypass and gastrectomy. Bypass achieves a higher remission rate but has a higher risk of complications. Other surgical procedures are being developed, and swallowed or laparoscopically placed balloons can shrink the available stomach, but these procedures are not well tested or widely available yet.
If you do consider metabolic surgery, the decision of which procedure depends largely on your preference and the surgeon’s experience. According to Cleveland Clinic guidelines, “Surgeon experience and hospital volume directly affect outcomes in bariatric surgery and should play an important role in determining which procedure to perform.”
Finally, check around. Dr. Rosenthal stresses safety, advising, “ASMBS accredits centers with proper equipment and experienced physicians and a complete team. We look at their care before, during, and after surgery. We monitor centers for quality and improvements.” Find an experienced surgeon with an accredited facility (see “Bariatric Surgery Resources“).
A good program should include psychological evaluation and support, education and training, patient support groups, and careful long-term follow-up. Given the potential risks and benefits, take all the time you need to decide about surgery, consider alternatives, and find the right providers. You will also find helpful information in books (see “Bariatric Surgery Resources“) for help deciding whether surgery is right for you.