Weight-loss surgery may be a better way to treat diabetes than traditional drug therapy alone, according to a study that found the operation was more likely to keep the chronic condition at bay for at least three years.
People who were overweight or mildly obese gained the same benefit from surgery as those who were heavier, a finding that should expand use of the procedure, said Philip Schauer, the lead researcher and director of the Bariatric and Metabolic Institute at the Cleveland Clinic. Most insurance companies limit coverage to those who are morbidly obese or have other medical conditions.
More than 23 million Americans suffer from Type 2 diabetes, when the body doesn’t properly use or make enough insulin to convert blood sugar into energy. The majority, about 80 percent, are overweight or obese. While earlier research showed surgery helped control blood sugar levels almost immediately, even before patients lost weight, there were doubts about whether the improvement would last.
“In some ways the gap between the benefit of surgery and medical treatment was even greater over time,” Schauer said, since the improvements after the operation persisted and patients getting only intensive drug treatment worsened over time. “Not only is it more effective at getting to a good blood sugar control, even to near normal levels, it maintains that.”
The health benefits weren’t limited to blood sugar control, according to the study of 150 patients presented today at the American College of Cardiology meeting in Washington. Patients undergoing surgery needed fewer blood pressure and cholesterol drugs and reported improvements in quality of life.
The study was simultaneously published in the New England Journal of Medicine. It was funded by Johnson & Johnson, which makes surgical staples used in the $25,000 surgery, the Cleveland Clinic and the U.S. National Institutes of Health.
More than 500 million people worldwide are obese, according to the World Health Organization. In the U.S., more than 44 percent of adults may be obese by 2030, according to a report from the Trust for America’s Health and Robert Wood Johnson Foundation. Obesity-related health costs in the U.S. now top $168 billion annually.
Heart doctors are coming around to embracing weight-loss surgery, even as they lament the need for it.
“It’s unfortunate we have to resort to surgery,” said Mariell Jessup, president of the American Heart Association and medical director of the Penn Heart and Vascular Center at the University of Pennsylvania in Philadelphia. “But our guidelines recognize that obesity should be considered a disease and we need to approach it that way.”
Jessup, who wasn’t involved in the study, has seen the benefits of surgery even in her sickest patients with heart failure, saying “it’s unbelievable how quickly they improve.” The weigh-loss procedure has other advantages, including making people feel better, allowing them to exercise more and helping manage their blood pressure and fluid volume, she said.
All patients in the study were treated with aggressive medical therapy. One-third also underwent gastric bypass surgery, where part of the stomach is closed off and a small remaining pouch about the size of an egg is connected further down to the small intestine. Another third has a gastric sleeve, where the stomach is reduced to the size of a banana.
The more extensive bypass surgery slashed patient’s weight by almost 25 percent. Their average three-month blood sugar levels were at less than 6 percent for one-third of them, below the American Diabetes Association’s recommended target and close to normal levels. The sleeve patients lost 20 percent of their body weight and 25 percent hit the study’s blood sugar target.
Patients relying on medicine alone lost 4 percent of their body weight and 5 percent met the study’s blood sugar goal three years after it began.
After three years, 69 percent of patients getting gastric bypass and 43 percent of those with the sleeve no longer needed diabetes medicines, compared with 2 percent getting drug therapy. More than half of the patients who didn’t get surgery still needed insulin, compared with fewer than 10 percent of those who got an operation.
While diabetes went into remission in some surgery patients, longer and larger studies are needed to see if the benefits help avert blindness, kidney disease, amputations, heart attacks and other long-term complications from the disease, the researchers said.
There are potentially serious side effects from surgery, including bleeding, leakage, blood clots and infection. Dumping syndrome, where undigested food moves too quickly into the small bowel and causes cramps, nausea and diarrhea, developed in 8 percent of those getting gastric bypass. Anemia became a problem for 31 percent of those who received a gastric sleeve.
The surgery isn’t for everyone, said Sidney Smith, a cardiologist and professor of medicine at the University of North Carolina at Chapel Hill.
“Although the results of bariatric surgery are very impressive in reducing diabetes and the need for medication, these procedures aren’t without side effects and complications,” Smith said. “We need to keep that in mind.”