No quick fix – bariatric surgery as a treatment option to obesity

Sunette Swart tells about how bariatric surgery is a tool for treating obesity. Though, she highlights it’s not a shortcut to weight loss as the patient will still have to put in effort after surgery.


Defining obesity

Obesity is defined as a chronic (long-term), progressive disease with episodes of remission (improvement in weight) often followed by relapse (regain of weight). It has multiple causes with behavioural, hormonal and neurological elements and can lead to almost 200 different health problems, including diabetes (high blood glucose) and hypertension (high blood pressure). It is a treatable condition, and it has been shown that even a 5% weight loss or more can reduce the risk of complications and improve overall health.

Obesity treatment options include lifestyle changes (healthy eating, increased physical activity, stress management, mental health, and good sleep quality), medication, and bariatric surgery. Behavioural changes or lifestyle changes alone can account for a 5-15% weight loss, whereas bariatric surgery can result in 35-40% up to two years after surgery.

Bariatric surgery

Bariatric surgery is derived from the Greek word “baros”, which means “weight.” The first weight-loss surgery was performed in 1953, and bariatric surgery has since evolved into what is now known as metabolic surgery.

To qualify for bariatric surgery, you must be between the ages of 18 and 65 years, with a body mass index (BMI) of 40kg/m2 or more or a BMI of 35 kg/m2 or more together with at least two co-morbid conditions (like diabetes, high blood pressure or high cholesterol).

Bariatric surgery can be done via a small, keyhole cut (laparoscopic) or with a larger cut, determined by the surgeon.

There are three types of bariatric surgery procedures:

  1. Restrictive procedure – This is a sleeve gastrectomy and gastric banding procedure (less used). After this surgery, the stomach is about 80% smaller (pouch) and this causes earlier satiety and delays gastric emptying.
  2. Malabsorptive procedures – Bilio-Pancreatic Diversion with a Duodenal Switch (BPD-DS) and Single Anastomosis Dueodeno-Ileal with Sleeve Gastrectomy (SADI-S), where fewer nutrients are absorbed.
  3. A combined restrictive and malabsorptive procedure – The Roux-en-Y gastrectomy (RYGBP) procedure.

Sleeve gastrectomy

The sleeve is performed when approximately 80% of the stomach is removed, leaving a small banana-shaped stomach that can hold around 50-150ml in volume. This results in smaller portions of food eaten and the hunger hormone, ghrelin, is reduced by removing a part of the stomach. Food then continues to pass through the small intestine in the same manner as before surgery, as shown in Figure 1.

Figure 1: Sleeve gastrectomy

Sleeve gastrectomy

Biliopancreatic diversion with duodenal switch (BPD-DS)

This procedure combines a sleeve gastrectomy with a much longer Y-shaped intestinal bypass than the RYGBP. The food bypasses about 75% of the small intestine, resulting in a decrease in energy and nutrients. As shown in figure 2, the bile and pancreatic digestive juices only mix with the food at the very end of the small intestine. The hormone changes caused by this procedure is far superior and causes a significant reduction in hunger, increases the feeling of fullness and results in excellent blood glucose control.  This is a highly complex surgery that can cause “dumping” (symptoms such as nausea, vomiting, abdominal cramping, diarrhoea, bloating, sweating, dizziness, and a fast heart rate), malnutrition, and loose stools. Protein intake and life-long vitamins are critical due to malabsorption (especially vitamins A and D).

Figure 2: Biliopancreatic diversion with duodenal switch (BPD-DS)

Biliopancreatic diversion with duodenal switch (BPD-DS)

Single Anastomosis Dueodeno-Ileal bypass with Sleeve Gastrectomy (SADI-S)

The SADI-S procedure is a newer variation of the duodenal switch that is easier to perform, takes less time in the operating room, and requires only one surgical bowel connection. The stomach is reduced in size by removing approximately 85% of it (same as the sleeve gastrectomy). The small intestine is then bypassed about 50% (longer than in the RYGBP).  This results in nutrient malabsorption due to the shorter path that digested food travels through the intestines, but with the benefit of added digestive enzymes, as illustrated in Figure 3. Bowel movements after this procedure are likely to be looser and more frequent.  Life-long vitamin supplementation is compulsory.

Figure 3: Single anastomosis dueodeno-ileal with Sleeve gastrectomy (SADI-S)

Single anastomosis dueodeno-ileal with Sleeve gastrectomy (SADI-S)

Roux-en-Y gastric bypass

The Roux-en-Y gastric bypass is regarded as the gold standard in weight-loss surgery due to its effectiveness and durability.  The name is a French expression that means “in the shape of a Y.” The stomach is divided into a small egg-sized pouch, and the larger part is bypassed. The small intestine is then divided into two sections, and the new stomach pouch is linked to the bottom end of the small intestine, which allows food to pass through. The top portion of the small bowel (where stomach acids and digestive enzymes pass from the “old” stomach) is connected to the small intestine during the final stage of the procedure, forming the Y shape seen in Figure 4.

As a result, the Roux-en-Y gastric bypass combines restrictive and malabsorption procedures. The patient eats less, feels fuller faster, and as the food bypasses contact with the first part of the gastrointestinal tract, there is less absorption. Gastric acid reflux is treated during this procedure. Life-long vitamin supplementation is recommended.

Figure 4: Roux-en-Y gastric bypass

Roux-en-Y gastric bypass

Hormone changes after bariatric surgery

Ghrelin, a hunger hormone produced in the stomach, stimulates the brain, increasing appetite and cravings for fatty foods. Because the stomach is smaller after bariatric surgery, less ghrelin is released, and patients’ appetites decrease. Leptin is another important hormone that regulates satiety, or the sensation of fullness. Following bariatric surgery, leptin levels rise, increasing fullness. Incretins are hormones secreted by the gut that regulate glucose levels via insulin release and affect appetite and gastric emptying. The most common of these incretin hormones, glucagon-like peptide 1 (GLP-1), is increased by bariatric surgery, resulting in improved blood glucose levels, decreased appetite, and slower gastric emptying. One of the reasons we see Type 2 diabetes remission after bariatric surgery is the improved GLP-1 effect on blood glucose.


Bariatric surgery in South Africa

Bariatric centres use a multi-disciplinary team approach, consisting of the surgeon, physician, registered dietitian, biokineticist and psychologist. There are several bariatric centres in the private healthcare sector in South Africa with varying accreditation with medical aids. At this time, a limited number of bariatric surgeries are performed in public hospitals, such as Helen Joseph Hospital in Johannesburg and Tygerberg Hospital in Cape Town.


Closing

Bariatric surgery is a tool for treating obesity. The success should be measured by weight loss and the improvement and/or resolution of co-morbid conditions, such as diabetes and hypertension. Continuous follow-up with your multi-disciplinary team is essential to ensure the long-term success of bariatric surgery with long-term lifestyle changes, for example,  healthy eating. Remember, no matter which procedure is chosen or performed, this is not a shortcut to weight loss. You as the patient will still have to put in the effort after surgery.


References available on request.


Sunette Swart

MEET THE EXPERT


Sunette Swart is a registered dietitian with 16 years’ experience in bariatric surgery. Her focus is on diabetes and obesity. She is an active member of a research team and a participant in international clinical trials. Since 2006, she has been a multi-disciplinary team member at Netcare Sunward Park Bariatric Centre of Excellence. Since 2010, she has been involved at the Sunward Park CDE clinic as consulting dietitian, led by specialist physician Dr A Murphy and a member of The Centre for Diabetes and Endocrinology (CDE). www.sadietician.co.za


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Five secrets for a good diabetes check-up

Diabetes nurse educator, Christine Manga, shares five ways to make the best of your diabetes check-up.


A man arrives at his local car workshop and asks to speak to the mechanic. He enquires whether the mechanic can help fix his car. “No problem,” replies the friendly mechanic. “Let me take a look.” The man answers quickly, “Oh, I haven’t brought it, but I can tell you what is wrong.”

Sometimes healthcare professionals (HCP) in the field of diabetes feel like that mechanic. We are so often asked, even expected to ‘fix’ the diabetes but we are not given the opportunity to see the glucose control or other health issues (the car). This simple analogy alludes to a diabetes check-up as perceived by an HCP.

On the other hand, the patient may perceive the diabetes check-up totally differently. More like a trip to the principals’ office, a nerve-wracking, dreaded experience.

These situations for both the patient and HCP can be avoided by following these tips.

  1. Bring the “goods”

Bring along a list of all the medications, prescribed and others you are taking, including the dosage. You can bring in the actual medication or a photo of the box or container (anything that will identify the medication). Unfortunately, HCP do not know what all tablets look like and there are at least 100 “little orange tablets” on the market. No treatment changes can be made without this information.

Your glucometer, diabetes diary or CGM are vital for all appointments. These should not be a cause for anxiety. Many patients do not test their blood glucose levels because they fear seeing high readings or are afraid of what the HCP may say. Analysing these readings together, high or not, will allow for better outcomes. An HCP will focus on fasting and post meal readings as well as any hypoglycaemic events (readings below 3,9mmol/L), trends and patterns. It is important to see if your readings are in keeping with your HbA1c.

A food diary is a good accompaniment to a glucometer. It allows you to realise the effects of certain foods on your blood glucose readings. This will enable you and the HCP to work on possible food alternatives or quantity changes. You can discuss any observations you have noted or concerns about these readings.

If your HCP has requested any blood or other tests be done, please ensure that they are done at least three days prior to the diabetes check-up. Bring any recent sonars, X-rays or specialist reports along.

  1. Be prepared

For your first appointment with your HCP, you will be asked about your family’s health history – is there a history of diabetes, strokes or heart attacks? If you have any disabilities of any kind, inform the practice so that steps can be taken to accommodate these. This may sound odd, but I have had a patient with hearing difficulties politely nod at me until we established that they couldn’t hear me. This is particularly important during this pandemic when masks are being worn.

A lot of information will be exchanged during the consultation. Bring along a friend or second set of ears as many things may be forgotten after the appointment. A notebook to write down instructions is also a good idea. Clarify any instructions by repeating them back to the HCP. Most HCP will take notes throughout a consultation.

Many patients, in my experience, are nervous or anxious during appointments. Having a list of questions and concerns you’d like to address with your HCP will prevent you from forgetting anything.

  1. Be honest

It bears repeating that it’s of vital importance that you are honest with your HCP. Remember, these diabetes check-ups are confidential. If you feel that you’re unable to be completely honest with your HCP, it may be worth considering changing your HCP.

Patients often feel, a natural urge, to tell their HCP what the patient thinks their HCP wants to hear. This is not in anyone’s best interest. The best outcomes are based on complete honesty. Don’t be shy about discussing problems with the HCP, there are probably many people with diabetes who have the same problem. Keep an open mind and give input on your treatment plan. Your HCP will be honest with you. This may mean that they are not able to answer 100% of your questions and may need to refer you to someone who can answer a specific question.

This honesty will range from the medication that you are taking and the doses you are omitting, food and exercise as well as your blood glucose readings. There are various reasons that patients omit medication doses, from side effects of the medication, cost, painful injections and genuinely forgetting to take it. These can all be dealt with if the HCP is aware.

Carbohydrates need not be lied about either; they are an important part of a healthy diet and need to be eaten. Let us know what you are eating/drinking and together we can plan the best way to incorporate these foods.

Elevated blood glucose levels do not always indicate a lack of effort or interest in ones’ own diabetes management. Multiple factors affect readings and these need to be discussed honestly and openly. Sometimes that elevated Hba1c may be due to the natural progression of diabetes and not that full slab of chocolate you plundered.

  1. Be consistent

Attending regular follow-up appointments with your HCP is important. It allows for timeous interventions when necessary. It forms the basis of managing a chronic condition, such as diabetes. If any change or intensification of treatment is required, early implementation can delay the onset of diabetes complications. On this note, staying in contact with your HCP between appointments is beneficial and can lead to better outcomes. Confirm what forms of communication the practice uses be it email, phone calls or WhatsApp. Ask about emergency contact details or hotline numbers.

  1. Relax

These appointments are for your benefit. Arriving anxious at your appointment can influence your vital signs, increasing your blood pressure to levels that you would not have in other settings. This is known as white coat syndrome/hypertension. Try to arrive at your appointment a few minutes early to enable you to wind down from any traffic stress. This appointment is yours, embrace it and make it meaningful.

eating time budget

MEET THE EXPERT


Christine Manga (Post Grad Dip Diabetes and Msc Diabetes) is a professional nurse and a diabetes nurse educator. She has worked with Dr Angela Murphy at CDE Centre, Sunward Park since 2012.


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Can Type 2 diabetes be reversed?

The good news is that Type 2 diabetes can be reversed; Dr Angela Murphy expands on the ways reversal can be achieved.


In short – yes, Type 2 diabetes can be reversed. However, it is neither easy nor possible for all patients. The word reversed somehow implies that diabetes will disappear never to be seen again. Most of my patients will ask this at some point, especially when the diagnosis is new, and I must emphasise that we do not have a cure for diabetes. It is possible to have remission of diabetes if certain criteria are met.

According to the American Diabetes Association these criteria are:

  • Full diabetes remission – fasting blood glucose (FBG) < 5,56mmol/L and HbA1c < 6,0% on no diabetes treatment.
  • Partial diabetes remission – FBG is 5,56-6,9mmol/L and HbA1c 6,0-6,5% on no diabetes treatment.

To consider whether it is possible to achieve remission, we need to take a step back and review what factors caused Type 2 diabetes to occur.

What factors caused the diabetes?

The human body requires an exquisite balance of systems to keep blood glucose in the normal range. Insulin produced by the beta-cells in the pancreas must be delivered throughout the body to do this. It is insulin that controls the amount of glucose produced by the liver when the body is in the fasting state, and insulin that regulates the uptake of glucose derived from food into the cells.

When a person gains excess weight, extra fat deposits in the liver and pancreas. This fat creates insulin resistance in the liver and so glucose production goes unchecked. In the pancreas, the fat interferes with normal beta-cell function. Eventually, the combination of increased insulin resistance and decreased insulin secretion causes diabetes. Although, there are always genetic influences, the main factor seems to be the excess fat.

Can the factor be removed?

Yes, most definitely with weight loss interventions. These are as follows:

Dietary

In 2011, the Counterpoint study showed that extreme calorie restriction could normalise blood glucose in a group of patients with Type 2 diabetes. The 11 study volunteers were given a liquid shake (Optifast – available in South Africa) and non-starchy vegetables totalling 600kcal per day. After the first week blood glucose levels dropped on average from 9,2mmol/L to 5,9mmol/L and remained there for the duration of the eight-week study. There was a significant improvement in insulin sensitivity in the liver and pancreas. This meant that the production of glucose in the liver decreased, and the pancreatic beta-cells could do their work again to control blood glucose. The average weight loss to achieve these changes was 15% of initial body weight.

The Counterbalance study, published in 2016, showed similar results in a larger group of patients with Type 2 diabetes who achieved normal blood glucose values for up to six months.

The DiRECT Trial, conducted in a general practice setting in the United Kingdom, showed diabetes remission in 46% of patients after a year and 36% of patients were still in remission after two years.  This showed that a calorie-controlled diet could induce diabetes remission. There is similar evidence for the use of a low carbohydrate diet as a dietary intervention to induce diabetes remission. There is still some debate whether it is the low carbohydrate intake per se or the associated overall drop in total calories that produces the benefit. In my experience, I like patients to follow diets they prefer as reducing calories is always hard work.

Surgery

Bariatric surgery has been used to treat obesity for many years. The sleeve gastrectomy, Roux-Y-gastric bypass and biliopancreatic diversion are the three main procedures.

The Swedish Obese Subject study followed several hundred patients with Type 2 diabetes who underwent bariatric surgery for over two decades. At the end of the second year, 72,3% of patients were in remission. This number decreased to 30,4% at 15-years post-surgery which is still significant.

We now talk about metabolic surgery which is defined as gastrointestinal surgery with the intent of treating diabetes and obesity. The improvement in glucose control post bariatric surgery occurs within days so it is not entirely dependent on actual weight loss. The significant drop in calories decreases the fat in the liver and pancreas restoring normal function in these organs. In addition, the levels of the gut hormone, GLP-1 (glucagon like peptide 1), increase which also increases insulin secretion from the pancreas. These changes lower insulin resistance and increase insulin production which decreases blood glucose. Many medical and scientific societies now endorse bariatric surgery as an effective treatment for Type 2 diabetes and a means to achieve diabetes remission.

What factors affect remission?

It has been shown that patients with longer diabetes duration, poor glucose control and low endogenous insulin production are less likely to achieve diabetes remission despite the above suggested interventions.

Patients choosing bariatric surgery will be assessed with one or other scoring method. The DiaRem score considers patient age, current HbA1c, the number of oral diabetic medications being used, whether the patient is on insulin and the duration of the diabetes. The higher the score, the less likely remission will occur, and this must be discussed with the patient prior to making any decision regarding surgery.

The type of bariatric surgery also affects the rates of diabetes remission with the more complex, malabsorption procedures (such as a biliopancreatic diversion) giving better results. The possibility of diabetes remission must be balanced against the possible risk of complications, especially long-term vitamin deficiencies.

Summary

The good news is that Type 2 diabetes can be reversed, and it is important that healthcare professionals discuss this possibility with patients. For many this will be information they can and will act on.

Bariatric surgery offers an excellent chance of diabetes reversal, but it is invasive and expensive. This makes it less accessible for most patients with Type 2 diabetes.

Lifestyle intervention should be a simpler option, but the calorie restriction is significant and for many people difficult to sustain. This is where newer medications, such as the GLP-1 receptor agonists (exenatide, liraglutide, dulaglutide and semaglutide) may help in the long-term use of very low-calorie diets.

It is vital to remember that good diabetes control decreases the risk of diabetes complications. It is much more beneficial to have good control with diabetic medications than fail at attempts to reverse diabetes and end up with poor control. To achieve diabetes remission is possible but not easy. To achieve diabetes control is possible and usually easier.


References:

  1. Lim, E.L., Hollingsworth, K.G., Aribisala, B.S. et al. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 54, 2506–2514 (2011).
  2. Steven S, et al. Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care 2016; 39: 808– 15
  3. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med (2002) 346(6):393–403.

MEET THE EXPERT


Dr Angela Murphy is a specialist physician working in the field of Diabetes and Endocrinology in Boksburg. She is part of the Netcare Sunward Park Bariatric Centre of Excellence and has a busy diabetes practice.


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