Issue 21 / 11 June 2013

AUSTRALIA needs to start providing bariatric surgery to severely obese people with diabetes before considering the appropriateness of offering surgery to patients with mild-to-moderate obesity, according to an expert in obesity research.

Professor John Dixon, head of clinical obesity research at Baker IDI Heart and Diabetes Institute, said Australia provided very little bariatric surgery to patients with diabetes who had a body mass index (BMI) over 40 kg/m2, despite recommendations by the International Diabetes Federation that bariatric surgery be a priority for such patients in whom medical management had not been successful. (1)

He said this group of patients was being “completely neglected”, particularly those in lower socioeconomic groups who were at higher risk of obesity and diabetes and were unable to afford private health insurance.

Professor Dixon was commenting after a US randomised clinical trial (RCT) and a systematic review found that bariatric surgery could also be beneficial for patients with a BMI between 30 and 35 kg/m2. (2), (3)

The 12-month clinical trial of 120 patients, published in the Journal of the American Medical Association, found that adding Roux-en-Y gastric bypass to lifestyle and medical management was associated with lower blood pressure and lower HbA1c and cholesterol levels.

Surgical patients also lost 26.1% of their initial body weight compared with 7.9% weight loss in the lifestyle and medical management group.

A systematic review, also published in JAMA, found that bariatric surgery in diabetes patients with a BMI of 30–35 kg/m2 was associated with greater short-term weight loss and better intermediate glucose control. However, an accompanying editorial said surgery was not necessarily the answer in these patients. (4)

“Bariatric surgery does result in substantial weight loss with excellent diabetes control but is offset by initial high cost and risks of surgical complications”, the author wrote.

The author also said the frequency and severity of complications in the RCT, particularly the devastating complication of an anoxic brain injury experienced by one patient, was problematic.

Professor Dixon said it was important to consider the risks and benefits in this group.

“While the risks of surgery may not be greater [than for patients with a higher BMI], the benefits of surgery may not be as dramatic and the data that we have is all short-term”, he told MJA InSight.  

Professor Dixon said it was crucial to consider more effective treatments for patients with diabetes in these lower weight ranges because many patients fell into this category.

According to a soon-to-be published cross-sectional survey of almost 2000 patients with type 2 diabetes (the MILES study), conducted by Deakin University and Diabetes Australia, the average BMI was 32 kg/m2.

Associate Professor Wendy Brown, director of Monash University’s Centre for Obesity Research and Education, agreed that more needed to be done to determine the risk–benefit ratio of offering bariatric surgery to these patients.

“At the moment we don’t really know enough about the potential for future disease and the outcomes of diabetes in these lower BMI patients”, Professor Brown said.

She said there was a school of thought that diabetes could be more severe in patients who developed the disease at a lower BMI, and the generally lower surgical risks in lighter patients may mean that the risk–benefit ratio comes out in favour of surgery.

She said complications were still an issue, however.

“We don’t want to replace one set of comorbidities with a new set of comorbidities and certainly operations like Roux-en-Y bypass, where we are diverting the food stream away from the digestive juices, do have long-term implications for nutrition”, she said.

Professor Brown said lap-band surgery was lower risk and reversible, so may be a better option for these patients.

Professor Joseph Proietto, who is Sir Edward Dunlop Professor of Medicine and head of the Metabolic Disorders Research Group at the University of Melbourne, said continual improvements in medical diabetes treatments meant that, at this stage, it was unnecessary to offer invasive procedures such as Roux-en-Y gastric bypass to diabetes patients with mild-to-moderate obesity.

“We are getting better and better at treating diabetes without such surgery”, he told MJA InSight.

“We have, for example, the [glucagon-like peptide-1] range of drugs that have come on line now — some of which cause mild weight loss.

“We will soon have renal glycosuric agents that also don’t cause weight gain and cause mild weight loss. We are beginning to understand obesity more and we will be getting better at treating obesity medically”, Professor Proietto said.

He said bariatric surgery was an option for people with diabetes and high BMIs, however.  

“In people who are massively obese, that’s a different question. Not only do they have diabetes, but they have multiple other comorbidities that would be helped by substantial weight loss”, he said.

 

1.    International Diabetes Federation 2011; IDF Position Statement on the Role of Bariatric Surgery
2.    JAMA 2013; 5 June (online)
3.    JAMA 2013; 5 June (online)
4.    JAMA 2013; 5 June (online)
 

4 thoughts on “Save surgery for severely obese

  1. Rosemary Stanton says:

    Having worked as a nutritionist for 47 years, I have yet to see the patient whose body weight is a mystery. And yet, largely because we are so poor at helping people change their eating and exercise habits, these important aspects of prevention and treatment seem to have been put into the too-hard basket.

    What we really need is much more research into why people choose inappropriate foods and much more ‘activism’ from the medical profession in getting governments to make obviously necessary changes to advertising and promotion of junk food and drinks (currently contributing well over one third of the average person’s kilojoule intake – even higher for children). Sport is also becoming too expensive for many people, footpaths are unavailable in many areas, public transport is inadequate and the ‘culture of fear’ generated by the media prevents many people from walking more. All deserve our attention.  

  2. Rob Tucker says:

       ‘Hear,hear’..Dr.Rosemary Stanton !

  3. Brunhilde (Bruni) Brewin says:

    There is always a reason why we do what we do.  Is eating inapropriately an addiction/habit, emotional or a health issue?  I would suggest that mostly it is an emotional coping method used as a bandaid.  If we changed the way we dealt with obesity that included going back to the original cause and deleting the cause, that then would delete the need to eat inappropriately.  By our current way of dealing with eating problems, we try to modify the symptoms, not the cause.  If we are inadequate with our current methods to release cause, then this needs changing.  Surgery as mentioned comes with its own problems.  Clients have put weight back on again despite having lost it in the first instance.  We have forced a situation that they now eat inapproriately in a different direction and have not taken the cause away.  I would be interested to have a study that shows the statistics in 5 years time to see how many of these surgery patients have put weight back on again.  I have had a few clients that have had surgery and have put the weight back on.  In other weight loss diets, research shows at the end of 5 years approximately  5.7% – 6% of people will have kept that weight loss, and others will have gone back to how they were or worse.  We have a situation where the way we deal with weight needs to change.  That is not just a belief, we can see that through the lack of being able to help clients to change.

  4. Sabri Caliskan says:

    I have been obese for 15-20 years and tried many diets & medications. Most diets worked short time and failed soon after relaxing the diet. I agree the life style is the essential factor but how many of us free to change their work and family commitments. It sounds beatiful, advicing great tips, diets and and trying to use science to prove you are right.

    You are not right. Diets are not working. Magic pills also same, gain weight soon after you stop them.

    Surgery works, and saves your life. I wasted my 15 years for trying to find the right diet for me. I wish I had the surgery years ago that could save my physical health as well as mental. I lost dozens of kilogram since gastric sleeve in February 2013. I can not advise more this surgery if you really want save your money, health and time. I know I am much less likely to suffer diabetus and cardiac problems which could cost my life and lots of trip to doctors, chemists etc.

    It is irrational also the medicare not covers the operation but covers the weight related disorders.

    And I was force to see dietician post operation as part of my surgery agreement. I did and failed again. Dietician adviced me to return the cereal and other foods in small portions. Wrong… I gain 3 kg with that advice only. Forget dietician, forget other tips. Surgery saves lives. I have seen it, and living in it.

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