Metabolic surgery as a
treatment for type 2 diabetes
Carol Franks Advanced Specialist Diabetes Dietitian
Diabetes Centre, Victoria Hospital, Hayfield Road, Kirkcaldy KY2 5AH, Fife [email protected]
PRE SURGERY
POST SURGERY
124.9kg
Average weight
86.5kg
Average % excess body
weight loss 68%
46kg/m
2
7.9
Average units of
79.2
mmol/mol
(9.4%)
Average HbA1c
insulin/day
The average age was 50.4 years. During the pre
surgery process patients had to demonstrate 5%
weight loss. Compulsory attendance at 6 group
psychology sessions was required.
Oesophagus
patients completed
the process but required
further psychology so did
not proceed to surgery
57.2
mmol/mol
(6.9%)
Average HbA1c
Pouch
Stomach
BMI, HbA1c, and % excess body weight loss were
noted at baseline, pre-operative and post operative at
6 weeks, 3, 6, 9, 12, 18 months and 2 years. Change
in diabetes medication was noted at referral, regularly
up to 2 years post surgery.
Diabetes medication was significantly reduced. Most
patients were recommenced on metformin for
cardiovascular protection.
Small intestine
At referral, 13 patients were on insulin, 11 patients were
on GLP-1 analogues, 14 patients were on metformin, 1
patient was on pioglitazone and 1 patient was on
gliclazide.
6
patients dropped
out of psychology
sessions
19
By 1 year 2 patients had recommenced insulin, 1 had
commenced saxagliptin and 1 commenced gliclazide.
By 2 years 4 patients were on insulin, 2GLP-1, 2 on
DPP4.
Food
Gastric juices
3
Average BMI
insulin/day
Dietetic intervention was delivered pre, peri and post
operatively. A very low carbohydrate diet was
implemented pre operatively to prepare for surgery.
Further diet plans were implemented post operatively.
2
31.9kg/m
2
Average BMI
134.8
Average units of
In Fife a pilot was initiated to investigate the
weight loss and change in glycaemic control
for a group of patients attending secondary
care Diabetes Centre. Inclusion criteria were
BMI>35 and referral for surgical treatment of
their diabetes by a Consultant
Endocrinologist.
BMI and many patients struggle to achieve
weight loss and optimal glycaemic control.
Metabolic surgery is a more effective
treatment for diabetes for certain overweight
subjects with Type 2 diabetes than medical
therapy.
Type 2 diabetes is a progressive disease.
Good blood glucose control is essential to
prevent the long term complications of
diabetes. 80-90% of Type 2 diabetes
patients are overweight or obese
(BMI>25). Insulin resistance increases with
Daily insulin dose decreased significantly by 94.2%
from an average of 134.81 units pre surgery to 7.9
units post-surgery at 2 year follow up.
declined
offered surgery
16 patients proceeded to surgery with 15 having roux-en-y gastric bypass, and
1 having vertical sleeve gastrectomy. All operations completed in 1 year May
2011 to May 2012.
Conclusion:
Gastric surgery is an effective treatment for Type 2 diabetes in the obese patient. A more positive outcome can be influenced by a strong engagement in the pre
surgery process. The emotional impact was powerful. The comments below only scratch the depth of the impact that obesity has on self esteem and stigma.
What the patients say...
Medical impact:”Not only have I been freed from the relentless
routine of 4 insulin injections a day and tensions of balancing
food, time, etc. but for the first time in ages I have perfect blood
glucose and no fear of hypos” “Since I first started putting weight
on at age 5, I have not been able to maintain weight loss in spite
of losing stones over the years. I now have victory in that area”
“No longer having to take insulin also feeling a lot healthier” “Off
all BP medication” ”I came off all diabetes meds, my sleep apnoea
went away” “Not being on insulin is my prize from surgery; the
weight loss was always a bonus to me.”
Functional impact:“Only bad point is other people thinking I
need to eat more. Pain in stomach but I am glad it is there as it
reminds me how lucky I was to have this chance for a better life”
“Able to wash myself without any help from others” “Fastening
the ordinary seat belt on a plane” “Able to shop in normal stores”
“Walking a lot more” “Travel more in comfort” “Having energy to
spend time with my children” ”In restaurants order what I want
without feeling everyone watching me” ”Can walk up aisle in tiny
buses” “Wearing matching underwear” “Walk better breathe
better” “Generally more in control, can control amount of what
eats rather than binge. Gaining confidence with food”
150
Outcomes measure at baseline, pre operative,
3,6,9,12,18 & 24 months
120
Emotional Impact Pros: ”Prior to the surgery was the counselling
that prepared us for it. Being able to deal with what has gone on
in our heads was a great help” “A new life is hard to describe.
Know you can do things you did 20 years ago again. Regain your
self-confidence” “Feeling great about myself and finally enjoying
life. I wish I felt like this years ago” “Feeling younger inside and
out” “Being able to live a normal life like other people” “More
confident in going into strange places/work situations” “Becoming
a positive member of society” “Feeling like I can actually join the
Human Race as an ordinary person” “A new Person (Happier”).
90
60
30
0
Emotional Impact Cons: ”Having so much loose skin which causes
sweat rashes in the folds, feel if removed it would give me my
proper weight loss” “Dumping after something sweet. Not being
able to eat certain things that managed before surgery. Not being
able to eat and drink at the same time” ”It is so much hard work
all the time, eating properly in all aspects, over almost 2 years, it
has become quite draining.” ”Having worked my way through the
initial changes, I find that being constantly cold difficult to cope
with.”
Weight
BMI
Acknowledgements
Type 2 Diabetes Metabolic Surgery Pilot Team. Research & Development Department.
% Excess body
weight loss
HbA1c
Baseline
9 months
Pre Operative
12 months
3 months
18 months
6 months
24 months