Part 2 – A deep dive into the treatment options for type 2 diabetes: Weight-Loss Surgery

This is the second post in a series exploring three very different treatment options for people living with type 2 diabetes, a common, lifestyle-related chronic condition.  

In the first post in the series, we explored the traditional medication management approach to type 2 diabetes. Here, we explore weight-loss surgery (WLS), which allows many patients with type 2 diabetes to no longer need medications and supports “diabetes remission” for a large majority. WLS is a dramatically different lifestyle and treatment pathway for patients with type 2 diabetes compared to traditional medication and medical treatments, but fewer than 1% of eligible patients receive it, despite WLS being recommended in the current national diabetes clinical guidelines.

About 24 million people in the US have “severe obesity”, qualifying them for WLS. Patients are eligible for WLS if they have a BMI greater than 40 or a BMI less than 35 if the patient also has chronic conditions, such as type 2 diabetes, hypertension, arthritis, asthma, sleep apnea, fatty liver, or heart disease. Nationally, 9.4% of Americans have diabetes, but this rate jumps to 25% among those who are severely obese.

The typical profile of a WLS patient is someone with a BMI of 40 or higher, unhappy with their excess weight, facing a growing list of medical problems, and feeling tired and burdened by failed weight-loss efforts. This patient often has a high-calorie intake, typically comprised largely of highly processed foods and sugar-sweetened drinks, and likely has been sedentary for many years. They may have signs of nutritional deficiencies (Vitamins D and B1, and iron) and the patient’s body is stressed metabolically from uncontrolled blood glucose, blood pressure, and blood lipids. These patients may have endured bias, stigma, and discrimination around weight, as physical and mental trauma are more common in this group. Most WLS candidates are motivated to overcome these life struggles.

WLS patients are typically looking for a “second chance” at life after years of experiencing frustrating weight fluctuations and unsuccessful attempts at permanent weight loss. Traditional weight-loss programs, such as Jenny Craig, Weight Watchers, and medically supervised programs can deliver a 5-10% weight loss and do improve health, but they are typically unsuccessful in the long term and experience high dropout rates. Many patients have experience with these programs, are aware of this reality, and some have turned to WLS as an alternate solution.

Most patients applying for WLS seek a solution that will offer them sustainable weight loss, hopefully leading to improved self-confidence, physical activity, and energy levels, and reducing the impact of severe obesity on their ability to live their life. By contrast, the surgical team and health-plan payers are typically focused on medical justifications for surgery, whether the patient is a good fit to undergo the surgery in terms of medical risk, and on ensuring the patient is psychologically and emotionally prepared for the dramatically new lifestyle awaiting them post-surgery.

What are the two main WLS options for type 2 diabetes patients?

There are two common types of WLS: gastric sleeve and gastric bypass. WLS dramatically changes the workings of the human digestive system and has far reaching effects on the patient’s food-consumption behavior, long-standing food habits, and food preferences. It also reduces the patient’s risk of early death from progression of disease and diabetes complications.

(image source: http://dishinaboutnutrition.com/which-is-better-the-roux-en-y-gastric-bypass-or-sleeve-gastrectomy/)

Gastric sleeve is the most common surgery, comprising 61% of all weight-loss surgeries, and the number of surgeries performed has tripled since 2011. It is less complex than the gastric bypass surgery, but it has strong weight-loss and medical outcomes. Gastric sleeve removes 80 percent of the stomach. The remaining stomach, which previously could hold a liter of food, becomes a pouch that resembles a banana. The small intestine is unchanged. The remaining stomach provides a much smaller reservoir for food. Patients can lose 80lbs or more in the year following gastric sleeve surgery, depending on starting weight.

Gastric bypass is used in 17.0% of all weight-loss surgeries and has halved in number since 2011. Gastric bypass alters the gastrointestinal tract to cause food to bypass most of the stomach and the upper portion of the small intestine. Gastric bypass reduces the stomach to the size of an egg (about 1 oz of food), dramatically limits calorie absorption, and sharply lessens the patient’s ability to eat high-fat, sugary foods without experiencing some gastric distress.

The remaining ≈22% of surgeries are comprised of two other, less common forms of surgeries and include revisions of unsuccessful ones.

The risk of dying from bariatric surgery is approximately 1 in every 1,000 patients who undergo WLS. This rate is lower than other common surgeries, such as gallbladder and hip replacement surgeries (<0.16%). All major surgeries have risk, including WLS; however, not getting the surgery means patients with type 2 diabetes live with a higher risk over their lifetime of diabetes-related complications, and they statistically are likely to face an earlier death without WLS or another effective remission treatment (see the final blog in this series on intensive lifestyle medicine).

The WLS clinical team stresses to the patient that success with gastric bypass surgery depends heavily on the patient’s ability to make permanent changes in their personal beliefs, attitudes, and food and physical activity habits. The patient must switch to real foods, avoid highly processed foods and sugary drinks, and they must eat small quantities, slowly. Patients are encouraged to build a new outlook on the role of food in their life, avoiding eating for emotional comfort and finding other activities to replace eating as a daily focus.

What is the patient’s experience and results with weight-loss surgery?

Patients must jump through many hoops before being approved for surgery, including a comprehensive evaluation by the surgeon, dietitian, clinical psychologist, and insurance navigator. It is also common for patients to need to lose some weight in preparation for surgery, which helps to reduce enlarged, fatty livers that impede surgery. Patients may also be required to go to group WLS education sessions. Surgery is followed by a nutrition plan of clear fluids in the hospital, with a transition to pureed then soft foods in the weeks to come. Eventually, the patient can consume real food in small quantities, while avoiding foods and drinks that are high in fat and sugar, and patients are encouraged to exercise caution with hard-to-ingest foods, such as raw vegetables or nuts. The meal plan is often highly tailored at this stage.

How does WLS help patients control their diabetes better and even go into “remission”?

Both gastric sleeve and gastric bypass surgeries directly improve blood glucose levels soon after surgery in ways not related just to weight loss, and surgery cause changes in key gut hormones (ghrelin, GLP-1, and PYY), which reduces hunger even with very low-calorie intakes after surgery. Diabetes remission rates are high following surgery (more than 60% for gastric sleeve and 80% for gastric bypass), and often even before significant weight loss has been achieved.

Reduced food intake, malabsorption, and a new intolerance of fats and sugars effectively changes the patient’s health. These new mechanisms are important in diabetes remission to help reduce toxic fat deposits built up from years of overeating and laying down excess calories as fat in key organs, such as the pancreas and liver. Putting the patient into a severe calorie deficit using healthy food choices, while the patient experiences little hunger, is a powerful combination. It increases insulin production and reduces insulin resistance, thus helping the body to stabilize blood sugars. Research also suggests that the gut microbiome (and balance of healthy versus unhealthy gut bacteria) is improved following surgery. There is a reduced inflammatory response from fat cells that become less metabolically stressed and secrete less cytokines, which in turn reset the body to a healthy leptin response (AKA the “fullness” hormone). This allows the brain to effectively detect fat stores in the body, burn them for energy, and improve appetite control. Patients are less hungry and lose fat quickly after WLS, and in a way that resets important systems that are critical to type 2 diabetes control (see figure). Many researchers are exploring this complex biology of WLS to create a clearer biopsychosocial model of its impacts.

What is life like for patients after surgery?

Life after surgery is different from the pre-surgery preparation phase, which includes a great deal of support from a comprehensive WLS team. After surgery, the treatment plan typically consists of tracking surgical complications, dietician visits (often not covered by insurance), and patient support groups. This creates an imbalance between the comprehensive team evaluation, education, and support that patients receive before and during the operation, compared to the lack of support they receive for the lifelong behavior and the psychosocial journey patients face afterwards.

Following the operation, patients must master a multitude of new behaviors and skills, including protein intake; lifelong vitamin supplement taking; eating behaviors; fluid intake; mental health and addiction management; physical activity; “dumping syndrome” reactions from high fat/sugar foods; and fruit, vegetable, and whole grain intake.

Patients also experience dramatic personal and social change, and the people around them, such as spouses, are impacted too. Patients must adjust to a new body, a new life, and greater social interaction. They also have to make psychological adjustments, such as experiencing attention from others regarding their new look and facial appearance.

Patients often report improved self-confidence with their body shape, new activity and energy levels, and the reduced need for diabetes medications. For patients with type 2 diabetes, other chronic conditions that see improvement following surgery include sleep apnea, asthma, non-alcoholic fatty liver disease, dyspepsia, and cardiovascular disease. However, all of this progress can be undone if the patient returns to old lifestyle habits following surgery and does not reach out to the weight-loss team for coaching and support. The risk of diabetes returning begins at 18 months to 2 years after surgery, especially if the patient stops coming to follow-up visits.

Despite dramatic weight loss and a new body shape, however, the patient can feel emotionally burdened by the constant effort needed to maintain this new lifestyle. Patients may be frustrated by the need to exercise several times a week to maintain their weight, or they may be sad that they had to give up comfort foods for those times when bored, unhappy, or stressed. Patients often need a good “listening ear” to validate these feelings, help them reframe their thinking, and find new strategies to keep their diabetes in remission if they are to continue to reap lifelong physical, emotional, financial, and social benefits from WLS. To date, only 25% of patients remain in remission at 5 years. This may reflect the imbalance between the level of support provided pre-surgery and what is needed for patients to achieve long-term success.

What would a WLS “Center of Excellence” for the 21^st century look like?

• We can build on progress in WLS for people with type 2 diabetes by continuing to refine the surgeries themselves (as has happened to date) and ensuring that the system provides more post-surgical support for patients. A new dimension must be added to WLS team care that sustains the initial, dramatic patient weight loss and that prevents remission. This new Center of Excellence must:
• Emphasize in pre-operative patient education how our modern US culture, food industry, and lifestyle have dramatically changed and fueled obesity and the chronic disease epidemics. This approach would bring together the perspectives of WLS and lifestyle medicine to create a stronger model that helps patients better understand the social and environmental forces that have led to severe obesity and that they must learn to safely navigate after WLS for long-term success.
• Explore value-based contracts with health plans and employer associations to engage them in a longer-term view of WLS outcomes and costs. Invest in more research and analytics to better demonstrate both the human and medical outcomes of remission that create total costs of care savings.
• Create WLS programs that target people with type 2 diabetes and lower BMIs (25-35 BMI range) to explore WLS as a safe and cost-effective option suitable for patients in this emerging risk category.
• Fix a missing piece of the puzzle. An important challenge for WLS patients is the large amount of excess skin remaining after substantial weight loss (1-2 years post-surgery). This problem should be included as part of treatment planning to help patients understand their options/costs.
• Expand WLS services to create a stronger post-surgical support system that reimburses registered dietitians to lead surgeon-supervised, telehealth-enriched, outreach and patient networking.
• Work with primary care to increase referrals, particularly for men who currently account for only 15% of WLS patients.
• Explore using new tools, such as Silver Fern Healthcare’s digital Behavior Diagnostic for WLS that assesses key self-management behaviors and psychosocial issues, bringing this new data into patient treatment plans, team workflows, and clinic management software, and supporting long-term patient weight loss and type 2 remission success.

Our final post in this series will focus on the third treatment option for type 2 diabetes: intensive lifestyle change. Similar to WLS, this option is a demanding, lifelong behavioral journey for patients, but it offers most patients with type 2 diabetes the opportunity of remission.

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