Recently,
two studies were published in the New England Journal of Medicine (NEMJ)
providing compelling evidence that surgical methods of achieving weight loss
can lead to better control of Type 1 diabetes mellitus (T1DM). It is well
established that weight loss in an obese person can show marked improvement in
the control of their DM.
As
we are well aware, while T1DM results from the body’s failure to produce
adequate amounts of the hormone insulin, Type 2 DM (T2DM) is a consequence of
improper utilization of this hormone. Regardless of the type, DM becomes more
difficult to manage as it progresses and ultimately leads to serious and severe
complications such as heart disease, kidney failure, blindness and stroke.
Crucial
to proper management of this disease is the adequate control of blood sugar
centered upon lifestyle measures that encourage weight loss and physical
activity. The weight loss regimen involving diet and exercise can be a mentally
and physically painful process with often a less than desirable outcome. Many
patients are unable to achieve good glycemic control, leading to the addition
of medications, frequently with increasing number and dosage, and ultimately
the addition of insulin therapy. Counter to the aim of the therapy, one of the
side effects of insulin therapy is weight gain, thus rendering management more
difficult.
It
is no surprise then that more patients are starting to resort to surgery to
decrease the size of their stomach. This type of weight loss surgery is termed
bariatric surgery and involves gastrectomy (removal of part of the stomach),
stapling or banding of the stomach. Although having been around for some time
now, an upsurge in cases of bariatric surgery for the management of DM has been
reported, mainly due to recent information from clinical studies that showed
significant weight loss and subsequent improvement in diabetic control. These
recent studies provide more dependable information because of their random and
rigorous comparison between medical and surgical forms of treatment. There is
now better proof that weight loss operations seem to work much better than standard
medical management.
Nevertheless,
caution must be employed and it may be wise to examine the studies in depth and
note their deficiencies. They involved only a small number of patients (150)
and were of a short duration. As well as not being able to prove long-term
benefits, it is also questionable if the results of bariatric surgery will be
as good in routine clinical practice, or for that matter, in patients who are
not as heavy as those in the studies. Since highly skilled surgeons performed
the operations in these studies, results by others may not be as good. Surgical
complications can range from infections, mineral and bone deficiencies and other
injuries. Furthermore, these studies compared bariatric surgery with standard
medical care involving medications, when in actual fact, the comparison should
have been with medical weight loss therapy (diet, exercise, behavior change and
other appropriate medical interventions). Patients succeeding with medical
treatment would then have no necessity to undergo surgery at all.
To
be fair though, bariatric surgery has been recognized as appropriate treatment,
but only for those obese patients with Type 2 DM who are unable to reach their
glycaemic targets with the prescribed medical therapies.
In
conclusion, we should not rush to embrace bariatric surgery as a standard
treatment alternative for DM despite the strong evidence suggesting so. Due
recognition has to be given for the hard work put in by the researchers, but
benefit must be shown in a larger numbers of patients, and over a longer period
of time before we can determine the place of bariatric surgery in the
management of Type 2 DM.
References:
Schauer
PR et al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients
with Diabetes. March 26, 2012 (10.1056/NEJMoa1200225)
Mingrone
G et al. Bariatric Surgery versus Conventional Medical Therapy for Type 2
Diabetes. March 26, 2012 (10.1056/NEJMoa1200111)
Zimmet
P, George K, Alberti MM. Surgery or Medical Therapy for Obese Patients with
Type 2 Diabetes? March 26, 2012 (10.1056/NEJMe1202443)
