Now add type 2 diabetes to the mix. If you’ve tried medications and lifestyle changes but are still struggling to get your A1C low enough — or are experiencing tingling and numbness in your feet — surgery can seem like a promising solution. But are you a candidate? All four of them leave the patient with a stomach that can hold far less food than before, and most of the options restrict the body’s ability to absorb calories and nutrients. (1) Since 2013, the sleeve procedure has overtaken all other procedures as the most commonly performed one, accounting for 59 percent of bariatric surgeries in 2017. That year, Roux-en-Y gastric bypasses (the most common procedure before 2013) made up 18 percent of the total. Lap bands represented 2 percent of bariatric surgeries, and the BPD-DS came in at less than 1 percent in 2017, per the ASMBS. (2) Here are the types of bariatric surgery, in detail:
Roux-en-Y Gastric Bypass (Gastric Bypass)
A surgeon creates a small pouch from the upper section of the stomach. Then the doctor attaches the lower part of the small intestine directly to the small stomach pouch, so that food can bypass most of the stomach and the upper part of the small intestine. Because the physical space of the pouch is smaller than the stomach, it cannot hold as much food at once, and the body absorbs fewer calories. The bypassed section is connected further down to the lower part of the small intestine. It is still attached to the main part of your stomach, so digestive juices can move from your stomach and the first part of your small intestine into the lower part of your small intestine. You still have both parts of your stomach, but only one small part holds the food you eat. The rerouting of the food stream creates changes in gut hormones that make you feel full when you eat, suppress hunger, and reduce high blood glucose, also known as hyperglycemia, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (1,3)
Biliopancreatic Diversion With Duodenal Switch (BPD-DS) Gastric Bypass
A surgeon creates a small, banana-shaped stomach pouch by removing a portion of the stomach, and then divides the duodenum (the first portion of the small intestine just beyond the stomach) so that about three-quarters of the small intestine is bypassed. The doctor brings up a segment of the lower part of the small intestine and connects it to the stomach. Finally, the bypassed small intestine, which carries the bile and pancreatic enzymes necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine. The rerouting of the food stream creates changes in gut hormones that make you feel full when you eat and suppress hunger. Of the procedures described in this article, BPD-DS is considered the most effective for weight loss and reducing high blood sugar. Yet it is most likely to have an adverse effect on the absorption of vitamins, minerals, and protein in the body. (1,3)
Laparoscopic Sleeve Gastrectomy (Sleeve)
A surgeon completely removes about 80 percent of the stomach from the body, leaving a banana-shaped pouch. The procedure drastically reduces the amount of food that can be consumed, and creates changes in gut hormones that make you feel full when you eat, suppress hunger, and reduce high blood sugar. (1,3)
Laparoscopic Adjustable Gastric Band (Lap Band)
In this procedure, which has largely fallen out of favor, the surgeon inserts a ring with an inner inflatable band and places it around the top of the stomach to create a small pouch. The band has a circular balloon inside that’s filled with saline (salt solution). A doctor can adjust the size of the opening from the pouch to the rest of your stomach by injecting or removing saline through a small port placed in your skin. After the initial surgery, the doctor adjusts the size of the band opening during several follow-up visits. If the band causes problems or is not effective enough for weight loss, a surgeon may remove it. Unlike with the other procedures, the body digests and absorbs food in a normal manner. Still, lap band procedures can help reduce high blood sugar, past research has shown. (1,3,4) According to the American Diabetes Association (ADA), an A1C level below 5.7 percent is considered normal; between 5.7 and 6.4 signals prediabetes; and over 6.5 percent indicates type 2 diabetes. (5) A review of 621 studies published between 1990 and 2006 found that 78 percent of participants who underwent bariatric surgery had a complete remission of diabetes. (6) Diabetes was either improved or in remission for nearly 87 percent of patients, with remission defined as being off diabetes medication with a normal fasting blood glucose of less than 100 milligrams per deciliter and an A1C of less than 6. In the same review, participants lost 56 percent of their body weight. Diabetes improvement, respectively, was greatest for those who had BPD-DS (95 percent remission), followed by gastric bypass (80 percent), sleeve gastrectomy (80 percent), and least for lap band procedures (57 percent). A small, randomized clinical trial published in JAMA Surgery supported the idea that bariatric surgery helps with weight loss in people with diabetes. (7) Researchers looked at three groups: those who had Roux-en-Y gastric bypass, those who had lap band procedures, and those who only had an intensive weight loss intervention. After one year, all groups underwent a “low-level lifestyle intervention,” which consisted of twice-monthly contact through one in-person session and one telephone call of less than 10 minutes, along with a series of continuing-education group sessions. Each intervention contact focused on a behavioral topic related to weight loss. After three years, 40 percent of the bypass subjects were in remission from type 2 diabetes or had prediabetes, as were 29 percent of the lap band participants. None of the people who lost weight from intensive lifestyle changes were in remission or had prediabetes. After three years, participants who underwent surgery were less reliant on medication, while medication use did not change among the lifestyle–weight loss group. Of those who were using meds at baseline, 65 percent of the bypass group and 33 percent of the lap band group had ceased using diabetes medication.
Gastric Bypass vs. Other Options
Another study published in The New England Journal of Medicine showed better results from Roux-en-Y gastric bypass alone. (8) The follow-up to an observational, prospective study found that among those who had type 2 diabetes before surgery, 75 percent were in remission after two years, 62 percent after six years, and 51 percent after 12 years. “Anytime you deliver nutrients to the bottom part of the bowel more quickly, which is what you do with those operations, it stimulates the bowel to produce more of those hormones,” Dr. Brethauer says. GLP-1 causes your pancreas to produce more insulin after you eat, thereby helping with blood sugar control, according to the Hormone Health Network. (10) Popular oral and injectable diabetes drugs known as GLP-1 receptor agonists — medications include semaglutide (Rybelsus) and dulaglutide (Trulicity Pen) — mimic the action of GLP-1 in the body and help to keep your blood sugar from rising too high. Meanwhile, the small intestine produces PYY before releasing it into the bloodstream after you eat. This hormone tells your brain when you’ve eaten enough, helping you feel full and curbing overeating, per the Hormone Health Network. (11) Altered gut hormones also may be the cause of a rare complication of bypass surgeries, particularly Roux-en-Y procedures, known as postprandial hyperinsulinemic hypoglycemia, or severely low blood sugar after eating, according to a position statement published in Surgery for Obesity and Related Diseases. (12) The ADA advises healthcare professionals to recommend bariatric surgery in people with type 2 diabetes who have a BMI equal to or greater than 40. That number is different — 37.5 — for Asian Americans, who typically have more visceral, or abdominal, fat compared with white people with diabetes of the same BMI. This abdominal fat heightens their risk for the disease, so the BMI of 40 is not a good value for this qualifying measure. Also, the ADA notes that bariatric surgery is recommended in adults with a BMI between 35 and 39.9 (32.5–37.4 in Asian Americans) who have other health problems, including hyperglycemia, and have not seen lasting weight loss and improvement in those other health problems using “reasonable nonsurgical methods,” per an article published in Diabetes Care. (14) “In addition to the BMI criteria, patients undergo a thorough multidisciplinary evaluation that covers nutrition, psychology, and a medical evaluation,” says Dr. Brethauer. “These visits are intended to identify behavioral issues that may impact their success after surgery and to optimize their medical conditions prior to surgery. Insurance companies currently require patients to undergo this multidisciplinary evaluation in order to be approved for the surgery.” But it isn’t always easy to get insurance coverage for surgery on people below the 35 BMI cutoff, says Eric DeMaria, MD, professor and chief of general and bariatric surgery at the Brody School of Medicine at East Carolina University in Greenville, North Carolina. The ASMBS argues that the cutoff is out-of-date, and people who have lower BMIs could benefit as well from having metabolic surgery to better manage type 2 diabetes. “They experience the same type of metabolic benefit from having the GI system reconfigured in the way that it’s done as part of the metabolic surgery,” noted an article published in Surgery for Obesity and Related Diseases. (15) There’s growing evidence that’s the case. A meta-analysis of 11 randomized clinical trials published in Diabetes Care reported that “type 2 diabetes remission rates following bariatric-metabolic surgery are comparable above and below the 35 kg/m2 BMI threshold.” (16) Despite the difficulties in getting insurance coverage, Dr. DeMaria suggests that people below the 35 BMI cutoff who are considering bariatric surgery have their doctors submit their request for insurance approval anyway, because some insurance companies will consider people with a lower BMI on a case-by-case basis. He points to a medical-policy update by CareSource for people on Medicaid in Ohio, stating that it will cover bariatric surgery if the individual has BMI of 30 or greater with type 2 diabetes and “inadequately controlled hyperglycemia,” such as an A1C of 8 or greater. (17) The next steps, she says, should be to: Look at your medication. Your doctor should assess if what you’re taking for diabetes or other health conditions promotes weight gain. Antidepressants, such as sertraline (Zoloft) or imipramine (Tofranil), or glucocorticoids, such as cortisone or prednisone (Sterapred), are examples of drugs that the ADA notes can cause weight gain. Also know that weight gain is a side effect of diabetes medication such as insulin and insulin secretagogues, including sulfonylureas, meglitinides, and thiazolidinediones. (14) Try diabetes medicines that are associated with weight loss. Metformin (Fortamet, Glucophage); GLP-1 receptor agonists, such as liraglutide (Victoza) and exenatide (Bydureon Pen); and SGLT-2 inhibitors such as canagliflozin (Invokana), are among the options that a doctor can prescribe, says Dr. Horn. (14) Then look at anti-obesity medication. The ADA recommends anti-obesity medication used with diet, exercise, and behavioral counseling, for people with a BMI of 27 or higher. The organization lists liraglutide (Victoza), as well as phentermine (Adiplex-P), orlistat (Alli), lorcaserin XR (Belviq XR), phentermine-topiramate ER (Qsymia), and naltrexone-bupropion ER (Contrave), as among the options approved by the U.S. Food and Drug Administration (FDA). If weight loss is less than 5 percent after three months, or if the person can’t tolerate a particular medication well, the ADA recommends trying other options. (14) “We should be looking at surgery if we can’t get that diabetes under control,” concludes Dr. Horn.
Intragastric Balloon Therapy (IGB)
A surgeon places one or more inflatable balloons into the stomach endoscopically or through a capsule that is attached to a catheter and swallowed. The balloons are then filled with saline or gas and then sealed to take up stomach space and delay gastric emptying. The devices are removed at a later date. (19) A past clinical case series of 143 consecutive participants found that after doctors removed intragastric balloons from 143 participants, the rate of type 2 diabetes fell from 32.6 percent to 20.9 percent. Furthermore, 12 months after removal, the incidence of diabetes remained at 21.3 percent. (20) But IGB therapy is not without its risks. As of June 2018, 12 people had died after having the devices placed, and among them, several developed a hole in the stomach wall within a few weeks of insertion, CNN reported. (21) Other problems have included sudden inflammation of the pancreas and balloons overinflating. The FDA has issued three letters to healthcare providers as of 2018 advising them to monitor patients for possible complications. (19)
Superabsorbent Hydrogel Capsules
This weight loss treatment involves swallowing a small gelatin capsule that contains hydrogel particles made from cellulose and citric acid. The calorie-free hydrogel particles absorb fluid in your stomach and expand to temporarily occupy space, helping you feel full. Once they reach the large intestine, water is released and reabsorbed, and the rest is eliminated in a bowel movement. The FDA approved it under the brand name Plenity (22), available by prescription. Another version of the device, which is designed to address weight loss and blood sugar management, is currently undergoing a clinical trial. (24) After surgery, continue these habits to help reduce the risk for complications, such as dumping syndrome, in which too-rapid movement of food into the small intestine can cause nausea, vomiting, abdominal cramping, and low blood sugar, according to the Cleveland Clinic. (25) Two weeks prior to surgery, you may be put on a very low-calorie diet, which involves drinking four to six high-protein, low-sugar meal replacements a day, in addition to imbibing about 64 ounce of fluids (preferably water) and continuing all vitamin supplements, says Turkel. “It is important to keep in mind those calorie restrictions are known to increase insulin sensitivity; therefore, there is greater risk for hypoglycemia. Patients on medications for diabetes must speak to the prescribing physician and notify them they will be following a very-low-calorie diet. They should check their blood sugar three to four times daily, and more frequently if the doctor indicates it.” Your doctor may need to adjust your insulin and oral meds accordingly, she adds. (26) Continue to see your healthcare team, who will help you adjust your medication regimen, recommend supplements, and acclimate to your new diet, notes UCSF Health. (27) Also, prepare yourself for changes that may result, from altered eating habits and weight loss to the way that you socialize and the relationships you have. Eating less may make mealtime less of a focus for you, affecting how you spend time with meal partners such as friends and family. It may also affect your romantic relationships. People who have undergone bariatric surgery have a higher probability of a major change to their relationship status, such as marrying, starting a new relationship, separating from a partner, or getting divorced, according to a study published in JAMA Surgery. (28) While such events can be traumatic, they can be the result of otherwise positive changes that happen after surgery. The study authors say their results are “in line with previous research showing that bariatric surgery is associated with increased quality of life, positive changes in social life, and increased romantic interest from others.” Indeed, for some, bariatric surgery can be a game-changer. One patient told Everyday Health that surgery not only helped him lose weight, but also lowered his A1C and helped him make better nutrition choices. He only wishes he’d done it earlier, in time to reverse the nerve damage to his feet that ultimately forced him to retire early. His advice? Two words: Don’t wait.
