ReviewDiabetes after Bariatric Surgery
Introduction
The prevalence of obesity and type 2 diabetes mellitus in North America and across the world has been increasing at alarming rates. Obesity is a critical risk factor for the development of type 2 diabetes. The relative risk for type 2 diabetes in individuals with obesity (body mass index [BMI] ≥ 30 kg/m2) is 10 times greater than in those with normal BMIs (≥18.5 to ≤24.9 kg/m2). In addition, 90% of all individuals with type 2 diabetes are overweight or obese (1). Although intensive lifestyle modification, with diet-induced weight loss, exercise and intensive medical therapy can result in good control and even remission 2, 3 of type 2 diabetes, the majority of patients find it difficult to achieve sustained control of blood glucose. In addition, intensification of medical therapy can lead to hypoglycemia and weight gain.
Therefore, many have turned to bariatric surgery (BS) or metabolic surgery for treatment of obesity and type 2 diabetes. Surgical weight loss provides marked improvement in glycemic control, with the rate of type 2 diabetes remission varying from 24% to 95% at 2 years, depending on the type of surgery, the definition of remission and the type of subjects enrolled 2, 4, 5, 6. The definition of remission varies from study to study but is generally defined as normoglycemia and glycated hemoglobin (A1C) levels below 6%, without the need for glucose-lowering medications for at least 1 year (7). Recent long-term data, however, suggest that relapse of type 2 diabetes is common in the years following BS. Here we review clinical studies of type 2 diabetes relapse after BS and discuss pathophysiology and determinants of type 2 diabetes relapse and its clinical implications.
Section snippets
Bariatric Surgery and Diabetes Remission
Anecdotal evidence of improved glycemic control after gastrointestinal surgery in patients undergoing gastric resection for peptic ulcer disease or gastric cancer was reported as early as the first half of the 20th century (8). In the early 1980s, surgeons recognized firsthand that many patients with type 2 diabetes undergoing Roux-en-Y gastric bypass (RYGB) experienced resolution of their type 2 diabetes. Pories et al conducted a retrospective single-cohort study of 298 patients with type 2
Risks and Benefits of Bariatric Surgery
Although BS can have numerous benefits, all surgical procedures and medical treatments are associated with risks. The rigorous preparation of patients, the development of centres of excellence and the elective nature of BS, now performed almost laparascopically, have reduced mortality and complications. Short-term 30-day postoperative mortality and longer term mortality associated with the surgical procedure is very low, less than 1% for all procedures and a bit higher for RYGB than for VSG or
Screening and Treatment of Diabetes after Surgery
A significant number of patients experience either persistent type 2 diabetes after surgery or, after a few months or years in remission, experience relapse in the years following their surgery. The distinction between persistent and relapsing type 2 diabetes may be important in terms of mechanism. However, the 2 may be hard to distinguish if diabetes status is not documented by longitudinal screening. Buse et al recommended at least a 5-year continuous state of complete remission before a
Conclusions
BS improves glycemia by inducing calorie restriction and sustained weight loss, thus improving insulin sensitivity and β cell function. Additionally, some surgeries, such as RYGB and VSG, may have weight-independent effects, possibly via enhancement of the incretin system and insulin secretion, particularly during meals. The International Diabetes Federation and the American Diabetes Association now recommend BS as a part of the algorithm in type 2 diabetes management 53, 54. Although BS does
References (54)
- et al.
Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass
Surg Obes Relat Dis
(2010) - et al.
Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up
Surg Obes Relat Dis
(2010) - et al.
Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial
Lancet
(2015) - et al.
Health-related quality of life after bariatric surgery: A systematic review of prospective long-term studies
Surg Obes Relat Dis
(2015) - et al.
Prevalence, severity, and predictors of symptoms of dumping and hypoglycemia after Roux-en-Y gastric bypass
Surg Obes Relat Dis
(2016) - et al.
Complications of bariatric surgery: Dumping syndrome, reflux and vitamin deficiencies
Best Pract Res Clin Gastroenterol
(2014) - et al.
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient: 2013 update, cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery
Surg Obes Relat Dis
(2013) - et al.
The continuing epidemics of obesity and diabetes in the United States
JAMA
(2001) - et al.
Bariatric surgery versus intensive medical therapy in obese patients with diabetes
N Engl J Med
(2012) - et al.
Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes
N Engl J Med
(2013)
Adjustable gastric banding and conventional therapy for type 2 diabetes: A randomized controlled trial
JAMA
Bariatric surgery versus conventional medical therapy for type 2 diabetes
N Engl J Med
Bariatric surgery versus intensive medical therapy for diabetes: 3-year outcomes
N Engl J Med
How do we define cure of diabetes?
Diabetes Care
Importance of the duodenal passage and pouch volume after total gastrectomy and reconstruction with the Ulm pouch: Prospective randomized clinical study
World J Surg
Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus
Ann Surg
Weight and type 2 diabetes after bariatric surgery: Systematic review and meta-analysis
Am J Med
Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus
Ann Surg
Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: The Diabetes Surgery Study randomized clinical trial
JAMA
Remission of type 2 diabetes after gastric bypass and banding: Mechanisms and 2-year outcomes
Ann Surg
Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications
JAMA
Glucose control and vascular complications in veterans with type 2 diabetes
N Engl J Med
Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes
N Engl J Med
Long-term effects of sleeve gastrectomy and Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus in morbidly obese subjects
Ann Surg
Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery
N Engl J Med
The importance of caloric restriction in the early improvements in insulin sensitivity after Roux-en-Y gastric bypass surgery
Diabetes Care
Early enhancements of hepatic and later of peripheral insulin sensitivity combined with increased postprandial insulin secretion contribute to improved glycemic control after Roux-en-Y gastric bypass
Diabetes
Cited by (34)
Comparison of various prediction models in the effect of Roux-en-Y gastric bypass on type 2 diabetes in the Chinese population 5 years after surgery
2023, Surgery for Obesity and Related DiseasesPredictors of type 2 diabetes relapse after Roux-en-Y Gastric Bypass: A ten-year follow-up study
2022, Diabetes and MetabolismCitation Excerpt :Bariatric surgery is considered to be an effective treatment for morbid obesity and represents a useful adjunct in the treatment of type 2 diabetes mellitus (T2DM) in subjects with severe obesity. The exact mechanisms behind diabetes remission after bariatric surgery are not completely understood, but improvement in insulin sensitivity and ß-cell function as well as changes in the entero-insular axis appear to play an important role [1,2]. Remission rates and diabetes-free time vary across studies, depending on the type of bariatric surgery and severity and duration of T2DM [3,4].
A nonhuman primate model of vertical sleeve gastrectomy facilitates mechanistic and translational research in human obesity
2021, iScienceCitation Excerpt :T2D remission associated with bariatric surgery often precedes significant weight loss and can persist despite weight regain, suggesting metabolic benefits stem from mechanisms more complex than simply a reduction in weight (Arterburn and Gupta, 2018). Although bariatric surgery provides remarkable clinical benefit, efficacy can decrease over time, especially in patients with the most pronounced preoperative metabolic dysfunction (Arterburn and Gupta, 2018; Arterburn et al., 2018; Shah and Laferrère, 2017), reflecting the gap in understanding of what factors promote the best metabolic response, as well as the identification of adjunctive therapies that improve the durability of the response to VSG. Despite more than a decade of research that has uncovered the metabolic benefits of bariatric surgery, the underlying mechanisms and specific contributions of complex integrated physiologic systems to metabolic changes remain incompletely understood (Batterham and Cummings, 2016).
Bile acids and metabolic surgery
2021, Liver ResearchCitation Excerpt :Metabolic surgery, also known as bariatric surgery, consistently leads to profound metabolic improvement such as weight loss, type 2 diabetes (T2D) remission, improvement of non-alcoholic fatty liver disease (NAFLD), and other metabolic complications.1–3
Improvement of glucose metabolism following rapid weight loss after bariatric surgery and its impact on reduction of visceral abdominal fat versus free fat muscle
2021, Surgery for Obesity and Related DiseasesCitation Excerpt :Glycemic control was excellent at baseline, which could be explained by the fact that most of our patients were under standard pharmacologic therapy for T2D and were followed by an internal medicine or endocrinology clinic. Although these improvements may not be clinically significant, they are well in line with previous research on the benefits of bariatric surgery on glucose homeostasis in patients with T2D [18]. As stated before, peripheral insulin resistance decreases and glucose homeostasis improves not only by decreasing visceral fat, but also by decreasing lean tissues.
Skeletal health after bariatric surgery
2020, Marcus and Feldman’s Osteoporosis
The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.