Gastric Bypass Treatment Lower BMI Non-Obese Diabetic Patients
The Challenges of Gastric Bypass as a Treatment for Lower BMI and Non-Obese Diabetic Patients
By Muhammad S. Feteiha, MD, FACS
For years, surgeons and patients alike have marveled at the improvements in type-2 diabetes within days or weeks of bariatric surgery – specifically, gastric bypass surgery. Until recently, it was assumed that dramatic weight loss and calorie restriction was the reason behind these marvelous results. However, there was a nagging question in all our minds – how did type-2 diabetes go into remission in so many patients within a mere few days or weeks of surgery…often before any significant weight was lost.1It was a question often pondered, but rarely researched – mostly because bariatric surgery was an option limited to the obese population. In other words, it was doing its job.
Today, diabetes is an ever-growing part of society, becoming a leading cause of illness and death in the United States and around the globe. However, gastric bypass remains a procedure limited only to those who are morbidly obese (with a BMI of 40 or over) or those with a BMI of 35 and over with one or more comorbid conditions such as diabetes. In other words, weight is still the primary driver for surgical candidacy.
The result is that while advocacy groups and surgeons alike are recognizing the potential benefits of bariatric surgery for a larger number of less- or non-obese diabetic patients, wider adoption remains challenging.
The Challenge of Acceptance by Non-Obese Patients
Bariatric surgery can help those with relatively lower BMIs too. Indeed, many patients with BMIs of 25-35 (considered overweight to obese) suffer from type-2 diabetes, or are pre-diabetic and have significant health issues that can be improved or resolved surgically. Recognizing this, to some degree, the FDA has approved the Lap-Band® gastric banding system for patients with BMIs as low as 30. However, these procedures are not nearly as effective on type-2 diabetes as a gastric bypass – and quite frankly their long-term risk profiles are not that much lower than the far more effective bypass.
Clearly, weight loss surgery has been branded improperly for years. After all, the weight loss benefit is simply a side-effect of the procedure’s primary purpose – disease improvement or resolution. Nowhere is this more obvious than in the case of type-2 diabetes. And while gastric bypass has been shown to improve, or resolve diabetes within days of surgery, regardless of significant weight loss, the nearsighted association between bariatric surgery and weight only remains.
Only recently, decades after first seeing the dramatic improvements in those with type-2 diabetes, are we starting to ponder the potential benefits of metabolicsurgery, even for those that may not qualify for surgery under traditional FDA guidelines and those that are not obese.
The solution? Education. Never have patients and healthcare professionals had more access to information than they do today. Gathering clinical data (more below), educating patients and referring healthcare professionals and getting governmental and influential societies on board can all work together to turn the tide.
The Challenge of Getting Sufficient Data
Acceptance of the gastric bypass’ effectiveness in managing type-2 diabetes, regardless of weight loss, is a relatively new concept and one that is poorly understood. As a result, we do not have the long-term data to support its wider-spread use outside of the obese population. Further, the funding and human resources needed to gather that data are not yet in place.
However, we do have decades of clinical data on the gastric bypass which shows incredible improvement or resolution potential for obese diabetic patients. This data also shows that the benefit may indeed be lifelong. Further, clinical data shows that obese patients without type-2 diabetes have a 60% lower chance of developing diabetes after bariatric surgery.
Bear in mind that this data is aggregated over several decades. Just twenty years ago most gastric bypasses were open procedures requiring 7-10-day hospital stays with potentially major complications. Today, surgical technique and technology has yielded amazing advancements in the safety and efficacy of the gastric bypass with hospital stays as short as 1-2 days and complications rates about as low as those of a gallbladder removal, in experienced hands.
At no time in the past has it been more important to direct funding to determining if gastric bypass surgery, or a derivative thereof, is indeed appropriate for those below the FDA’s current weight-based guidelines.
The Challenge of Payor Acceptance
As with most medical conditions, it is the payors (private insurance or Medicare/Medicaid) that accept novel treatments last. And without insurance participation, self-pay for gastric bypass is beyond the financial reach of most patients. However, once we overcome the first two challenges mentioned above, we will be able to make the case for a cost-effective and curative procedure that could potentially change the lives of millions of Americans.
Bariatric surgery was once a little known and poorly understood procedure to many doctors and patients. However, its overwhelming benefits, combined with a need for effective long-term intervention for a growing obesity problem brought it to the mainstream. Today, we see a similar trend – a surgical procedure that can improve or resolve type-2 diabetes in up to 90% of patients combined with a diabetes epidemic that is projected to affect over 55 million Americans by 2030 if trends continue.2Have we reached the dawn of surgical treatment for diabetes?
Dr. Muhammad Feteiha, FACS is a general and bariatric surgeon at Advanced Surgical Associates in Springfield, New Jersey. He is a Fellow of the American College of Surgeons and is past president of the New Jersey Chapter of the American Society for Metabolic and Bariatric Surgery (ASMBS).
Abbasi J. Unveiling the “Magic” of Diabetes remission after weight-loss surgery. JAMA. Feb 14, 2017; 317(6): 571-574.
Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: Insights from Yesterday, Today,Back To All Posts