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+++++++++++++++++++++++++++++++++++++++++ + +++ +SPECIAL SECTION: CHRONIC DISEASE +++ +++++++++++++++++++++++++++++++++++++++++ Bariatric Surgery Seen as Way to Cure Diabetes By Mark Pozsgay, DO B not just about weight loss but also about fixing metabolic conditions. As clinicians today tackle the worldwide obesity epidemic, there is now consensus that the most effective and long-lasting treatment for morbid obesity is surgical weight-loss intervention.1 While cosmetic improvements are a positive result of significant weight loss, the primary goal of bariatric surgery is to cure the constellation of associated diseases known as the metabolic syndrome and improve patients' quality of life and longevity. In addition to Type 2 diabetes, there are many other obesity-related conditions, including hypertension, sleep apnea, hyperlipidemia and GERD. Type 2 diabetes has been shown to be one of the most morbid conditions affecting obese individuals, and its prevalence highly correlates with body mass index. Nearly 26 million Americans have diabetes — since 8.3 percent of the population is affected. The number of people diagnosed with diabetes has dramatically risen from 1.5 million in 1958 to 18.8 million in 2010, now reaching epidemic proportions, accounting for the seventh-leading cause of death in the United States.2 In addition, the number of diabetic people under age 20 is rising alarmingly, paralleling the obesity epidemic affecting children and adolescents in many western countries. For decades, bariatric surgeons have observed resolution of diabetes with 22 ARIATRIC SURGERY IS | Cleveland/Akron/Canton MD NEWS surgically induced weight loss. More recent studies have demonstrated the various degrees of effectiveness of different bariatric procedures. Currently performed laparoscopic operations include gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. The effectiveness in improvement and resolution of Type 2 diabetes increases in this particular order and is mediated by various mechanisms including not only weight loss, but also alteration of hormonal signals and pathways. Taken together, these bariatric procedures have shown to completely resolve 76.8 percent of Type 2 diabetes and also to resolve or improve this condition in 86 percent of patients.3 Two recent randomized controlled studies have shown weight-loss surgery to be far superior to medical management alone in treating Type 2 diabetes. These studies sought to evaluate the efficacy of Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) in comparison with optimal medical therapy. The surgical group was able to achieve more than a threefold improvement in obtaining targeted hemoglobin A1C levels as compared with the medical group — 42 percent LRGYB, 37 percent LSG for surgical group and 12 percent for medical group. The results provided substantial evidence for the metabolic benefits of such procedures, leading to the conclusion that surgery is far superior in not only controlling, but ■ MDNEWS.COM ■ JANUARY/FEBRUARY 2014 also curing Type 2 diabetes. While the currently accepted criteria for qualification for bariatric surgery remains a body mass index (BMI) greater than or equal to 40 kg/m2, which corresponds to roughly 100 pounds over ideal weight, or a BMI between 35kg/m2 and 39.9kg/m2, which corresponds to roughly 75 pounds overweight, along with a comorbid condition, such as diabetes, hypertension or sleep apnea4, these studies have shown surgery to be efficacious in patients with BMI as low as 27kg/m.2,5 These findings point out that the role of metabolic surgery in the treatment of obesity and Type 2 diabetes may need to increase. Dr. Mark Pozsgay is a board-certified, fellowship-trained bariatric surgeon for Summa Health System. He has delivered a number of research and oral presentations on the topic bariatric surgery and obesity. ■ 1 Zografakis, JG. Summa Bariatric Care Center 2012 Outcomes 2 National Diabetes Education Program, http://ndep.nih.gov/resources/ResourceDetail. aspx?ResId=108 3 Buchwald H, Estok R, Fahrbach K, et al. Weight and Type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009 4 National Institutes of Health (NIH) Consensus Conference on the Surgical Management of Obesity, 1991 5 Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. Philip R. Schauer, M.D., et al. N Engl J Med 2012