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Surgery Beats Diet and Exercise for Diabetes Remission

Another study is adding to the evidence that bariatric surgery is probably the best bet we have for diabetes remission. In a randomized, controlled clinical trial, David Cummings and colleagues found that surgery beats diet and exercise for remission of type 2 diabetes. In this relatively small, well-controlled study, 60% of surgery patients had remission of their diabetes after a year, compared to just 6% who in the control group that received intensive lifestyle intervention with diet and exercise. The average BMI of people at the start of the study was between 37 and 38. The minimum to participate was 35. The authors concluded:

Our trial and other relevant RCTs demonstrate that commonly used bariatric/metabolic operations (RYGB, sleeve gastrectomy, and gastric banding) are all more effective than a variety of medical and/or lifestyle interventions to promote weight loss, diabetes remission, glycaemic control, and improvements in other CVD risk factors, with acceptable complications, for at least 1–3 years.

So why are people so slow to consider it? The answer is complicated, but it boils down to three major factors: stigma, risk perceptions, and money.

Stigma works in two ways. Both the disease of obesity and the surgery that can treat it so effectively are highly stigmatized. People living with obesity are commonly told, even by doctors, that they ought to be able to “get it under control” themselves. But worse, research shows that further discrimination awaits people who clear the hurdles to treat their obesity with bariatric surgery.

That stigma helps fuel false risk perceptions that deter people from considering surgery, even when it would be a good option for them. “Why have a risky surgery when I ought to be able to control this myself” represents a very common line of thinking.

All that stigma and self-doubt sets up a situation ripe for health insurers to exploit for their financial advantage. Bariatric surgery commonly costs between $15,000 and $25,000, which is a pretty reasonable cost for a procedure that can be life changing and life saving. Health plans restrict coverage because they can — the outcry is muted. Though coverage is improving, lengthy approval processes and high out-of-pocket costs are common. It’s enough to deter many people who need this treatment.

Despite these barriers, utilization is growing steadily. The American Society for Metabolic and Bariatric Surgery estimates that the number of bariatric surgeries grew by 22% between 2011 and 2014. This follows a significant drop in surgeries after the Great Recession of 2008.

The burden of type 2 diabetes is growing dramatically. With the growing recognition that surgery is the best bet for putting it into remission, we can expect that its utilization will continue to grow, perhaps at a quickening rate.

Click here to read the study in Diabetologia, here to read more from Medical Daily, and here to read more from the Associated Press.

Win! Photograph © Kris Baylon / flickr

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March 20, 2016

10 Responses to “Surgery Beats Diet and Exercise for Diabetes Remission”

  1. March 20, 2016 at 8:53 am, Allen Browne said:

    Ted,

    You are so right – again. Stigma from the healthcare provider, stigma from the patient, and stigma from society even after successful treatment. With the knowledge we have now the stigma seems so wrong and so easily refutable, but obviously is not that easy.

    And diabetes is the easy comorbidity to work with – easily measured and easily followed with objective parameters like blood sugar, HgA1c, insulin, necessary meds. What if we had such available parameters for quality of life, bullying, bias, heart disease, liver disease, orthopedic issues, cancer, dementia, etc?

    Thanks for this very valuable addition to our knowledge. One step at a time.

  2. March 20, 2016 at 9:39 am, Ted said:

    Thanks, Allen!

  3. March 20, 2016 at 10:03 am, gerry stanewick said:

    You were at the FDA meeting for VBLOC and you fail to mention them as they are much safer then bariatric.

  4. March 20, 2016 at 10:50 am, Joan Ifland said:

    Of course, we should take into consideration that most diet advice coming from diabetes educators includes advice to eat processed foods and take medication to ‘compensate.’ I think on a non-addictive, clean food plan, diet would beat surgery easily. Just my opinion.

  5. March 20, 2016 at 7:21 pm, Ted said:

    Thanks, Joan.

  6. March 20, 2016 at 7:22 pm, Ted said:

    Thanks, Gerry. I think VBloc can be useful for some patients. Of course, for the subject of this article, diabetes remission, we have no data that VBloc provides a benefit.

  7. March 21, 2016 at 11:38 pm, Bruce Daggy said:

    I’m surprised at the number of people randomized to surgery who withdrew from the study. I would have expected a higher initial dropout rate from the lifestyle group, on the logic that most people volunteering for this study would be hoping to be randomized to receive a $20k medical procedure and follow-up for free. Anyone with that hope who was randomized to lifestyle might not be motivated to proceed with the study or to go all-in for the lifestyle approach. But after an initial 15% dropout in the lifestyle group, on average these subjects made headway. That’s a credit to the study team. The study shows that surgery can work, but both arms show that surgery is not for everyone — even when it’s free. Surgery was performed on fewer than 1% of the subjects screened. That’s a long way short of suggesting surgery as the answer.

  8. March 22, 2016 at 4:01 am, Ted said:

    Thanks for taking the time to comment, Bruce.

    I read that ILMI was provided for free, but I did not see that said of the surgery. All of the patients had insurance coverage for surgery. I would agree that surgery is not THE answer. It is simply the best we’ve got for someone with type 2 diabetes and obesity. People in the IMLI group “made headway,” but 94% of them did not achieve a remission of their diabetes. Diabetes is a bad disease with bad outcomes.

    Any surgery is intimidating. Bariatric surgery is especially intimidating. But quality of life data and medical outcome data confirm what I see in the lives of many people I know who have had surgery. Their lives are greatly improved.

  9. March 23, 2016 at 11:25 am, Bruce Daggy said:

    Ted, thank you for the clarification about insurance coverage, I missed that. I agree that surgery is an effective solution for some people. But there is a practical challenge. You recently posted that the majority of Californians have diabetes or pre-diabetes; whatever the precise figure is for the country, it’s daunting. How can surgery make a significant dent in the problem of diabetes when the prevalence and incidence are both high? Surgery is the most effective answer to diabetes. Cheap generic drugs are the most pragmatic answer. Neither is the ideal answer we are looking for.

    Thanks for all you do to foster discussion & learning.

  10. March 23, 2016 at 4:55 pm, Ted said:

    You are right, Bruce. The options we have are inadequate. But right now, we are just telling people with obesity, “shoo!” And for a variety of reasons, only the smartest ones figure out that they have options for improving their health now. Others just say, “I guess this is my fate.” Everyone needs options. Everyone needs hope.