In part two of this series I will examine another means of achieving type 2 diabetes remission: bariatric surgery. In part one I explored the benefits of the low carb approach and how, as a dietitia, it is extremely exciting to see this dietary shift have such a positive impact.
Bariatric surgery
The first evidence for type 2 diabetes remission comes from evidence in bariatric surgery. Bariatric or weight loss surgery is considered by many to be underutilised and the most effective treatment in those with severe and complex obesity (1), and is cost-effective (2).
My first clinical experience of type 2 diabetes remission came about during my first rotation as a dietitian in a busy London teaching hospital. I shadowed a colleague in a post-op dietetic bariatric clinic. The lady was four weeks post op, 10kg down, with insulin and gliclazide both stopped day one post-surgery. In clinic, her blood glucose levels were perfect. Excuse me?! I was not taught this in University!
Embarrassingly, I had never heard of remission. I was taught that type 2 diabetes is a chronic, progressive disease and we should ‘manage’ it with the same dietary advice that we advise to the rest of the population. I remember having lunch with the bariatric registrar that day; he was amused at my excitement of seeing remission for the first time.
As time goes o, I start to learn more about bariatric surgery and start to undertake pre- and post-op clinics. I hear the most wonderful stories. Patients arriving into clinic with 10k medals, old pairs of jeans which they could now fit into one leg of, proudly showing pictures of themselves with grandchildren playing in the park. Something they never could have done before surgery.
It’s not the ‘easy way out’
Bariatric surgery, despite popular belief, is far from the ‘easy way out’. It’s often seen as the ‘final option’ for people with obesity, after years and years of struggling with diets, exercise and weight stigma. I am yet to meet a patient undergoing bariatric surgery who has not tried to lose weight multiple times in the past.
As per national guidelines, patients must attend a specialist service for 1-2 years including many appointments with specialist nurses, dietitians, psychologists, bariatric physician and surgeons. Surgery is not guaranteed for any patient, and often patients are deemed not fit or not right for surgery by the multidisciplinary team. Some think of a bariatric service as some sort of ‘assembly line’ where each and every patient is operated on without much consideration. This is not true, and insulting to the hours of hard work undertaken by patients and healthcare professionals alike.
However, it is not all a walk in the park and as with any surgery, it does carry risk of complications. I had one lady who I used to see every week, had a feeding tube placed while she waited for revisional surgery, because she was unable to tolerate anything more than just a few sips of water. Many people have undergone surgery and not made the appropriate lifestyle changes alongside, and have regained the weight lost. It takes a dedicated patient and a supportive team.
Bariatric surgery can be a powerful catalyst for change. Guiding the patient, openly and honestly through the expectations and letting them know that bariatric surgery is both a challenging a life-changing experience is critical for best positive outcome.
Bizarrely, we would often have patients show up to bariatric assessment clinic, not realising they had been sent for bariatric surgery assessment, with absolutely no interest in having bariatric surgery. Why? Was the referrer not confident or comfortable to have this discussion with the patient? I urge primary care doctors and other healthcare professionals to engage with bariatric services and understand the criteria and evidence behind bariatric surgery. HCPs must be confident in being able to open these conversations to patients. This surgery is life saving for many people.
In part three of this series I explore the impact of very low energy diets in regards to type 2 diabetes remission.
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Tara Kelly
Registered Dietitian & Research Associate
Dietitian at Diabetes Digital Media
References
- Rubino, F., et al., Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care, 2016. 39(6): p. 861-77.
- Keating C, Neovius M, Sjoholm K, Peltonen M, Narbro K, Eriksson JK, et al. Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects study. Lancet Diabetes Endocrinol 2015;3: 855-865.
