By Virginia Anderson
WebMD Health News
Reviewed by Brunilda Nazario, MD
Sept. 8, 2014 -- Weight loss surgery is an expensive and potentially risky way to treat type 2 diabetes. Yet more studies are showing it can also be very successful -- in some cases, more so than drugs and lifestyle changes.
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Despite what experts are calling "remarkable" results, though, they're not saying weight loss surgery is a cure.
And it's not for everyone, they stress.
Here's what they do know: A recent study found that type 2 diabetes can stay in remission for as long as 15 years after weight-loss surgery. Remission happens when a person with diabetes achieves blood sugar levels no longer in the diabetes range without medications for at least one year.
Surgeons who routinely do the surgery say they're not surprised at the study's findings. It showed that 30% of people with type 2 diabetes were in remission 15 years post-surgery, compared to 7% whose diabetes was managed with drugs and lifestyle changes.
Surgery could be a life-saver for certain obese people with diabetes, experts say. They include people who:
- Have tried to lose weight by traditional methods but could not
- Have had trouble managing their diabetes
- Had had diabetes for less than 4 years
Even among people with diabetes who are good candidates, surgery should not become the first treatment they try, experts say.
"We are absolutely the last stop. We are there for the person who has tried everything," says Richard Stahl, MD. He's the medical director of bariatric surgery at the University of Alabama at Birmingham.
Recovering from surgery can take up to 2 weeks. Also, people who get surgery must still make major lifestyle changes to keep the benefits.
"It's not a simple fix, it's a big ordeal to qualify for, and it's not simple to recover from," Stahl says.
Nor is it typically covered by insurance, according to the American Society for Metabolic and Bariatric Surgery. The recent findings from this study and several others are expected to add to discussion about whether insurance guidelines should be broadened to include the surgery for less-obese people -- and also about whether surgery is the best way to treat diabetes.
The average cost of weight-loss surgery ranges from $11,500 to $26,500, says Amber Hamilton, a spokeswoman for the society. Costs depend on the type of surgery and where it's done. Three types are common in the U.S. -- bypass, gastric sleeve, and gastric band. Insurance companies vary in their reimbursement policies, Hamilton says. The procedures are covered under the Affordable Care Act in 22 states, she says.
Diabetes has been on the rise in the United States for decades, climbing to 29.1 million in 2012, according to the CDC. It's marked by ongoing high levels of blood sugar, and it can lead to heart disease and stroke, blindness, kidney failure, amputation, and premature death. The estimated direct and indirect economic cost of diabetes care grew to $245 billion dollars in 2012, a 40% increase from $174 billion in 2007, according to the American Diabetes Association.
Type 2 diabetes accounts for 90% of those with diabetes. Most people with type 2 are obese, which causes insulin resistance and trouble controlling the disease and its complications.
But many with diabetes have a hard time managing the disease with drugs and lifestyle changes.
Also, weight gain is one of the side effects of insulin and some other medications used to treat diabetes.
Insulin is "a life-saving medicine, but it can make you gain more weight," says John Morton, MD. He's the chief of bariatric and minimally invasive surgery at Stanford University Medical Center
The disease can be expensive, too. People with diabetes can spend about $13,700 a year in medical costs, according to a 2013 report from the American Diabetes Association. Of that, about $7,900 is tied to diabetes. In a report published in April 2014, Express Scripts said that "medications used to treat diabetes were the most expensive traditional therapy class when ranked by per-member-per-year."
Surgery Pros and Cons
Morton and other surgeons say they've seen dramatic drops in insulin levels in their patients post-surgery over the years.
"It was considered a weight-loss operation, but it is truly a metabolic operation," Morton says.
That said, no one quite understands how that happens, so more study is needed.
"The surgery itself only works well when you do these other things," says Marc Bessler, MD, a weight-surgeon at Columbia University Medical Center.
A benefit of the surgery is that patients are often more inclined to exercise, Bessler says. "Think about what it is like to exercise if you are one hundred pounds lighter."
But even if people lose as many as 100 pounds from the surgery, their diabetes is unlikely to go into remission if they've had the disease for more than 4 years. Cells in the pancreas called beta cells that make insulin die off over time and cannot be replaced.
"If you've lost a large chunk of your beta cell population, you're not going to have the same benefit," says Dana Portenier, MD. He's a weight-loss surgeon at Duke University School of Medicine.
Some doctors say the recent study isn't perfect.
The authors "don't go into what kind of lifestyle changes there were, and how intense," says Taraneh Soleymani, MD. She's the co-director of Weight Loss Medicine at the University of Alabama School of Medicine.
But "I would recommend it if the diabetes is not well controlled," says endocrinologist Richard Siegel, MD. He's the co-director of the Diabetes Center at Tufts Medical Center. "Bariatric surgery is the best we have for getting weight and blood sugar down over a long period of time."
SOURCES: Marc Bessler, MD, chief of minimally invasive and bariatric surgery, Columbia University Medical Center, NYC. Amber Hamilton, PR person/spokesperson for the American Society of Metabolic and Bariatric Surgery, NYC. Melanie Mabrey, PhD, NP, endocrine nurse practitioner, Diabetes Center, Duke University School of Medicine, Durham, NC. John Morton, MD, MPH, chief of minimally invasive and bariatric surgery, Stanford University Medical Center; president-elect of American Society of Metabolic and Bariatric Surgery, Palo Alto, CA. Richard Siegel, MD, co-director, Diabetes Center, Tufts Medical Center. Dana Portenier, MD, weight-loss surgeon, Duke University School of Medicine. Sjorstom, Lars J. Journal of the American Medical Association, June 11, 2014. Taraneh Soleymani, MD, co-director, Weight Loss Medicine, UAB, Birmingham, AL. Richard Stahl, M.D., medical director, UAB Bariatric Surgery, Birmingham, AL.
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