Bariatric surgery

Bariatric surgery is a treatment option for obesity and diabetes in patients whose body mass index (BMI) is ≥ 35 kg/m2 and glucose levels aren’t controlled despite the best efforts with medications and lifestyle modification.

BMI is calculated as follows: BMI = weight (kg) ÷ height (m²).     

Bariatric surgery has been a major advancement in treatment of people living with obesity and diabetes in recent years. Between 70 and 90% of these people will still be in diabetes remission two years post-surgery. Remission is defined as normal blood glucose on no diabetes medication for at least a year. Even 15 years after bariatric surgery, a third of people will still be in remission. Of those that need diabetes treatment again, simpler regimens achieve glucose control. 

There are a variety of procedures available, and this should be individualised by the bariatric centre which will be staffed by a full multi-disciplinary team: surgeon, specialist physician, dietitian, psychologist, and exercise therapist.

The benefits extend beyond improving glycaemic control, as multiple other comorbidities (hypertension, sleep apnoea, high cholesterol) are also positively affected. 

Bariatric surgery has few complications, but regular structured follow-up is essential. Particular attention must be paid to those complications relating to nutritional deficiencies since the stomach and intestines are responsible for absorbing nutrients from food eaten.

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Insulin pump therapy

Insulin pump therapy, also known as continuous subcutaneous insulin infusion, uses a small, computerised device to deliver insulin continuously in the way a functioning pancreas would. Only short-acting insulin is used for both the background and mealtime requirements.  

Insulin is administered via a plastic tubing connected to the pump on one side and a small cannula inserted through the skin. The subcutaneous site can be on the abdomen, outer thigh, outer arm, or top of buttock. The abdomen is usually the preferred site. The site needs to be changed every three to four days to prevent infection or inflammation.

A background basal rate is set up to give insulin continuously. This rate will vary over the 24 hours of a day depending on the requirements. 

For mealtimes, you will need to give a bolus insulin dose. To do this, the blood glucose value and amount of carbohydrates (in grams) is entered into the pump. The amount of insulin needed to cover the carbohydrates is pre-programmed. In the same way the on-board computer will calculate how much insulin is needed to correct a high blood glucose reading.

Some pumps can communicate with continuous glucose monitoring devices which has brought a new level of accuracy. The most sophisticated of these systems allows the pump to adjust basal insulin according to requirements, switch off insulin delivery if glucose levels drop to low and give small boluses of insulin to correct glucose levels starting to rise. This system has been dubbed the artificial pancreas. 

People with Type 1 diabetes are ideal candidates. However, people with Type 2 diabetes who inject insulin four times a day can also benefit. Unfortunately, pumps are expensive and only worth considering if you have medical aid that will cover the costs.

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Oral medication

All patients with diabetes are initiated on medication at diagnosis. People with Type 1 diabetes will require insulin replacement due to the damage to the pancreas. People with Type 2 diabetes are prescribed oral medication according to international and national guidelines. In addition, lifestyle measures including a balanced diet and exercise are recommended for both types of diabetes.

The first medication prescribed to people diagnosed with Type 2 diabetes is metformin. This can be given as a daily extended-release pill, or twice daily normal formulation. The dose is increased according to average glucose levels. Metformin improves the action of insulin in the liver and thus, decreases the production of glucose from the liver. Similarly, it helps the work of insulin at the level of the muscle to absorb glucose from the bloodstream. 

Metformin benefits and side effects

Metformin also has benefit in protecting the body against the abnormal, complication-inducing complexes that form when glucose levels are high. For this reason, metformin is continued life-long for benefits beyond just lowering of glucose. 

The side effects of concern are gastrointestinal, especially diarrhoea, bloating and nausea. Some patients can’t tolerate metformin at all but for many who develop side effects, a lower dose allows them to continue treatment. ( The daily extended-release formulation also seems better tolerated.

Other classes of agents

If diabetes isn’t controlled, as measured by HbA1c, three months after initiating metformin, then a second agent needs to be added. There are four classes of agents: sulphonylureas (increases insulin secretion); dipeptidyl peptidase inhibitors; thiazolidinediones; and sodium-glucose like transporter-2 inhibitors (results in sugar being flushed out of the body via the kidneys). 

A non-insulin injectable can also be used; these are the glucagon-like peptide receptor agonists. These latter agents help with weight loss as well as HbA1c control.

Type 2 diabetes is a progressive condition. This implies that periodically there will be further deterioration in control and at some point, the pancreas may not produce enough insulin. This may require one to four injections of insulin daily to supplement what the body needs. There is no doubt that a healthy diet, weight control and regular physical activity will slow this progression.

Side effects

It’s possible that you may have some side effects when taking oral medications but it’s important that you don’t stop taking your medicine without speaking to your doctor first. Side effects usually settle down once your body gets used to the medicine. Check the patient information leaflet that comes with your medicine for more info. 

The most common side effects include a metallic taste in the mouth, nausea, vomiting, or diarrhoea. Some of the medications may cause hypoglycaemia and you should report this to your doctor immediately. The medications which work through the kidney can increase the risk of urinary and genital infections which need to be speedily treated. Again, you need to alert your healthcare team.

Management of diabetes in the modern age includes maintaining a balanced lifestyle and appropriate medications so that you may be assured to decreased risk of complications.

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Insulin lowers blood glucose by stimulating the uptake of glucose into your muscles and fat and stops the liver from producing and releasing more glucose into the bloodstream.

Insulin is the first-line treatment for people diagnosed with Type 1 diabetes as pancreatic destruction means they don’t produce their own insulin. 

People with Type 2 diabetes or gestational diabetes who don’t achieve good glucose control on oral agents will also need to be initiated on insulin. Often people starting insulin feel that they’ve failed in their efforts to manage their diabetes with exercise and diet. Starting insulin isn’t a reflection on discipline or perseverance. Often insulin is the only therapy that can control blood glucose and improve management. It shouldn’t be seen as a last resort or as a punishment.

Types of insulin:

  • Basal or long-acting insulin is usually taken once a day and provides insulin coverage over 18 to 24 hours.
  • Bolus or rapid-acting insulin is taken before meals to prevent a spike in blood glucose from food. An additional amount (correction dose) may be added to lower an already high blood glucose. This usually reduces high blood glucose quickly and will remain in your body for three to five hours.
  • Mixed insulin is a mix of long-acting and rapid-acting insulin. It’s usually taken twice a day before breakfast and dinner and has eight to 12 hours of coverage in your body. The initial amount of insulin will be faster-acting with smaller amounts in your body after five hours. 

Your doctor will discuss which option would be preferable depending on the features of your diabetes. It’s ideal to also see a diabetes educator and dietitian when you start insulin. The diabetes educator will provide education about how to use insulin and help to make any necessary adjustments. The dietitian will discuss the best strategies for eating.

Side effects

The most common side effect is hypoglycaemia (blood glucose level < 4mmol/L). People using insulin should always carry a fast-acting carbohydrate with them, such as sweets or juice, as well as a blood glucose kit. Patients requiring high doses of insulin can also experience weight gain. Adjusting carbohydrate intake can assist with this.

Tips for effective use

  1. The insulin pen in current use can be kept at room temperature while all spare insulin is stored in the fridge. Using a cooler box or gel pack is useful if insulin has to be kept in the car.
  2. Speak to your doctor about using insulin cartridges instead of disposable pens as these are often cheaper and fully reimbursed by medical aids.
  3. Looking after injections sites is vital which involves changing the needle after every third injection and using different sites each time.
  4. When initiating insulin, your dose may need several changes so keep in close touch with your doctor or diabetes nurse. One dosage change every few months isn’t adequate.

Optimal control with insulin is dependent on your individual requirements which is assessed by checking your blood glucose regularly. 

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