Mr. V is a 42-year-old businessman who has had diabetes for the past eight years. He is five feet six inches tall and weighs 126 kg. Two years ago, he was advised by his doctor to start insulin injections, since his blood sugars were not controlled with tablets. He has been taking insulin regularly, but he has noticed, to his alarm, that his weight has gone up by 11 kg since he started insulin. He is careful regarding what he eats and makes an attempt to exercise regularly. His doctor, suspecting that the weight gain is due to insulin, has tried reducing the dose on a couple of occasions, but each time he does this, the sugar levels shoot up.
Mr. V is in a quandary. He does not want to gain any more weight; at the same time, he is acutely aware of the ill-effects of high sugars and fears that any reduction in insulin dose will adversely affect his diabetes control.
The situation described above will be familiar to many patients with diabetes as well as the physicians treating them. Management of diabetes, especially in its later stages, often involves striking a balance between the benefits of treatment and the side-effects. Weight gain is a major side effect of diabetes treatment, which often thwarts the best efforts of doctors and patients to attain near-normal blood glucose levels.
Type 2 diabetes, the most common variety of diabetes, is characterised by two major defects in the body. In the initial stages of the disease, at least, the individual’s pancreas puts out a fair amount of insulin; however, the blood sugar levels remain high. This indicates that the individual has insulin resistance i.e. he or she is unable to respond normally to the biological actions of insulin. If this situation persists long enough, the pancreas eventually gives up the fight and the individual goes in for absolute insulin deficiency. This is the stage at which most patients would start requiring insulin injections.
In addition to its effect on blood glucose, insulin also has an “anabolic” effect, meaning that it promotes growth and multiplication of cells in the body. People with type 2 diabetes tend to be resistant only to the sugar-lowering effects of insulin but not to the anabolic effect. This means that they readily gain weight when they are given insulin injections to control their blood sugar levels. Some of the commonly used diabetes tablets also cause weight gain because they promote the release of insulin from the pancreas. Also, some people with diabetes, who have experienced low sugar symptoms (hypoglycemia), get so terrified of developing another episode that they take to eating extra to prevent the sugars from dropping too low. Added to this are the various accompanying illnesses that prevent patients with diabetes from adhering to the prescribed diet and exercise regimen — diabetic foot problems, osteoarthritis, heart disease, gastric problems and dental problems). It is, therefore, not surprising that many people with diabetes end up gaining considerable amounts of weight.
What can you do to prevent weight gain if you need to be on medications for diabetes? While some diabetes medications can make you gain weight, some of them do not have any effect on weight or can even help you lose weight. Do discuss your concerns with your doctor so that he can advise the most appropriate treatment. Even if you require insulin injections, you can minimise the amount of weight you gain by eating smart and exercising regularly. This way, you will need less insulin to control your sugars and your doctor will not be forced to increase your doses at every visit. Also, if you maintain regularity in your meal timings, you are unlikely to develop hypoglycemia and will not be forced to eat more just to avoid this from happening.
Unfortunately, many people with diabetes either cannot lose weight, or go on gaining weight in spite of their best efforts. Typically, these individuals have high sugar levels in spite of taking multiple medications and high doses of insulin. Any reduction in insulin dose leads to loss of weight, but the sugars shoot up and vice-versa. Many of these persons are more than 50 to 70 kg above their ideal body weight. What can you do if this is the case?
This is where the role of surgical treatment of diabetes comes in. Surgery has been used to promote weight loss for nearly 70 years now, but it is only recently that its beneficial effects on diabetes have been recognised. In a nutshell, there is now evidence that certain surgical operations can help patients with diabetes to get their blood sugar levels to normal without medications, and maintain it that way, for considerable lengths of time. This is termed “remission” of diabetes.
Bariatric (or metabolic) surgery refers to a group of surgical procedures that help people to lose weight, by altering the anatomy of the stomach and intestines. There are two major types of bariatric surgery. In the first (restrictive) type, the size of the stomach is reduced either by removing part of it, or by placing an adjustable band around it, so that more than a certain amount of food cannot be ingested at any given time. The second (malabsorptive) type works by creating a new passage bypassing the nutrient-absorbing portion of the intestines. Reduced absorption of nutrients leads to weight loss.
Both these types of surgery have been found to be effective in weight loss as well as improvement in diabetes. Both of these can be carried out through a laparoscope and are relatively safe procedures in experienced hands. The hospital stay is also extremely short.
Are all patients with type 2 diabetes candidates for this approach? While anyone can lose weight after these procedures, those who are the most overweight or obese would obviously derive the maximum benefit, both in terms of weight loss as well as diabetes control. Also, the individual should be willing to have regular follow up and to strictly follow the diet advised; otherwise they may end up regaining much of the weight lost and the diabetes control will worsen.
Losing those extra kilos, therefore, makes all the difference in your fight against diabetes. You can prevent the development of diabetes, make its control easier and improve your quality of life just by watching your weight. Surgical treatment of obesity now offers patients the possibility of knocking off excess weight, as well as controlling diabetes, in one shot!
After considering all available options, Mr. V’s physician recommended that he go in for surgery to help achieve weight loss as well as control of diabetes. In the six months following the surgery, Mr. V has lost 40 kg in weight. He has been able to stop his insulin injections completely and the number of diabetes tablets has come down from five to two. His blood sugar levels are absolutely normal. His doctor is confident that very soon, he may be able to stop his last two tablets as well. Mr. V has achieved a partial remission of diabetes, thanks to the weight loss surgery.