Is Diabetes a Medical or Surgical Disease?

For which obese patients with type 2 diabetes is bariatric surgery appropriate?

When discussing type 2 diabetes mellitus, there is good news and bad news. The good news is that the armamentarium for treatment has been growing with recent potent additions. The incretins have revolutionized contemporary management, and multiple insulin formulations are available. Hemoglobin A_1c (HbA_1c) measurements and home monitoring provide essential information.

Unfortunately, the bad news still outweighs the good. Type 2 diabetes can be characterized as “one of the fastest growing epidemics in human history.”¹
It is a progressive disease that eventually exhausts beta cell function. Medical therapy only partially achieves HbA_1c or other targets.² The bad news also translates into a staggering international cost. Global spending on this disease was estimated to be $376 billion dollars in 2010; estimates for 2030 are expected to top $490 billion!^{2
____________________________________________________________________________________________________________________________________________________________________________________________________________________}

RELATED CONTENT
Bariatric Surgery Benefits Patients with Type 2 Diabetes
Is Diabetes a Medical or Surgical Disease?
____________________________________________________________________________________________________________________________________________________________________________________________________________________

TREATMENT OF TYPE 2 DIABETES IS EVOLVING

Is there a better way to proceed? Although type 2 diabetes has always been considered a medical disease, will it evolve into a surgical disease? A common international denominator for the disease is obesity. Bariatric surgery has become a successful adjunct. Because of the obvious connection between type 2 diabetes and obesity, two “Top Papers” and an accompanying editorial may provide a glimpse into the evolving care of patients with diabetes.^1-3

The first study enrolled 60 patients (ages 30 to 60 years) with a body mass index of 35 kg/m² or greater.¹ All had had diabetes for 5 or more years. Patients were randomized to surgical intervention (gastric bypass or biliopancreatic diversion) or medical therapy. After 2 years, no patients in the medical limb had remission of their diabetes. However, 75% and 95% of the gastric bypass and biliopancreatic diversion groups, respectively, experienced remission (HbA_1c values of 6.35% and 4.95%, respectively, as well).

The second study compared intensive medical therapy to medical therapy plus either Roux-en-Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes.² The end point was an HbA_1c value of 6.0% or less 1 year later. Medical therapy alone achieved the end point in 5 of 41 patients. In the medical-surgical limb, 42% and 37% (gastric bypass and sleeve gastrectomy, respectively) made the target HbA_1c.

IS BARIATRIC SURGERY THE UNIVERSAL PANACEA?

The editorial asks the toughest question, “Is surgery, then, the universal panacea for obese patients with type 2 diabetes?”³ The answer is, “Not yet.” All studies to date have been short term and were composed of small cohorts. The surgical procedures may have complications, there can be psychological fallout, and micronutrient deficiencies may follow over longer periods. The editorialists also caution that remission does not equal cure. One thing is becoming clearer: the future of diabetes therapy will be changing and surgery may become a viable option.