Mrs. K (50) has had diabetes for eight years. She is 168 cm tall and weighs 155 kg with a body mass index (BMI) of 54.9 kg/m2. She takes four insulin injections a day along with several tablets, but her sugar levels are always high. More alarmingly, she has noticed that she has gained eight kgs ever since she started insulin four years ago. Whenever she attempts to reduce the insulin dose, her sugar levels shoot up. Moreover, she tends to snore, does not sleep well at night, is breathless and unable to walk a short distance even on level ground. Mrs. K would love to lose weight and most definitely does not want to gain any more. At the same time, she wants her diabetes to be under control.
Being overweight or obese are major factors predisposing individuals to the development of Type 2 diabetes. Excess body weight makes it difficult for the insulin secreted by the pancreas to work; this is called insulin resistance. Initially, the body tries to counter this by increasing the production of insulin but it is only a matter of time before the pancreas gives up the unequal struggle; at this juncture, diabetes develops.
Problems with body weight do not end there. Many medications used to treat diabetes cause weight gain; insulin being the prime example. Also, many patients fear low sugar when they are treated for diabetes and take to snacking on high-calorie foodstuffs. Add to this, the widespread reluctance to be physically active and you have a potent recipe for significant weight gain!
Although diet and exercise help in weight loss, for someone like Mrs. K, these lifestyle changes, while important, may not be sufficient. Moreover, these people often regain all the weight they lose. For such individuals, a simple stomach surgery now offers an attractive therapeutic option. There is now evidence that certain surgical procedures can help patients with diabetes get their blood sugar levels to normal without medication and maintain it that way for considerable lengths of time. This is termed “Remission of diabetes”.
There is also proof that obese individuals with “pre-diabetes” who undergo these surgeries are protected from developing diabetes in the future. 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 stomach’s size is reduced by removing part of it e.g., Sleeve Gastrectomy. The second (malabsorptive) type bypasses the nutrient-absorbing portion of the intestines; e.g., Roux-en-Y Gastric Bypass.
Both can be done through a small “key-hole” incision on the abdominal wall and are associated with little or no complications in experienced hands. The patient can usually go home in about three days. Our experience with these procedures over the last two years suggests that even resistant diabetes patients are able to stop or significantly reduce their dose of diabetes medication, including insulin, after bariatric surgery. On an average, the weight loss is around 20-30 kg, something that cannot be achieved through any other medical method.
In view of her uncontrolled diabetes and obesity, Mrs. K was advised to undergo bariatric surgery. She underwent Roux-en-Y gastric bypass. Following an uneventful postoperative period, she was delighted to find that her weight, as well as her sugar levels, came down. Six months later, she had lost 57 kg and now weighs 98 kg with a BMI of 34.7 kg/m2. She has been able to stop insulin injections and her sugars are under good control with just one tablet. Most importantly, her quality of life has improved tremendously: she feels much better and is even able to walk up a hill!
Bariatric surgery, hitherto considered only as a weight-loss procedure, has now emerged as an accepted treatment option for Type 2 diabetes, with the World Health Organisation and the International Diabetes Federation recommending these procedures for overweight and obese adults with type 2 diabetes. In the right patient, the right surgical procedure done at the right time by the right team of doctors has the potential to dramatically change life of the person with diabetes for the better.
The writers are Chennai-based Diabetologists.