Bariatric Surgery- A first choice or a last resort?

Dr. Sean Wheatley, PhD – Research and Trainer in Public Health/7 November 2016

Many of you reading this may well have watched the recent BBC Panorama programme; “Diabetes: The Hidden Killer” (though please stick with me if you haven’t!). Working for a charity that provides lifestyle management education (with some great successes) I was disappointed by the programmes failure to cover education based interventions, but more worrying still was the portrayal of bariatric surgery as some kind of diabetes silver bullet*! Although some of the limitations were touched upon in the programme the overriding message seemed to me to be that bariatric surgery can be the solution to the diabetes epidemic. But is this true?

What is Bariatric Surgery?

Bariatric surgery refers to a number of different procedures aimed at helping people to lose weight, primarily through reducing the space available within their digestive system for the food they consume to be stored and processed. The most common types are:

* Using a gastric band, which is placed around the stomach preventing it from expanding and consequently meaning less food is needed to fill it.

* Gastric bypass surgery, where the digestive system is re-routed; missing out most of the stomach, meaning that less food is needed to make someone feel full.

These procedures are not currently performed that regularly. There were only 5671 procedures in the UK in the 2014/15 financial year (less than 1 for every 10,000 people)(1). It has been suggested however that the surgery should be offered to more patients (2) or even that the requirements should be altered to make more people eligible.

What are the Benefits of Bariatric Surgery?

Recent systematic reviews and meta-analyses (the top level of evidence, if carried out well) have found conclusions highlighting the potential beneficial effects of bariatric surgery. One concluded that bariatric surgery could reduce all-cause mortality; i.e. less people died during the studies included in the review when they’d had the surgery (3), whilst another concluded that bariatric surgery leads to greater weight loss and higher remission of type 2 diabetes and the metabolic syndrome (a clustering of risk factors associated with elevated cardiovascular disease risk) than lifestyle change alone (4). Although there are a number of limitations to these reviews** the findings suggest that bariatric surgery can be used to good effect. 

So Should Everyone Have it?

Despite the evidence that bariatric surgery can be effective, there are some potentially serious risks to undergoing such procedures which should be considered (Source: NHS Choices):

 During the operation

* 1 in 1,000 risk of death (there is always an inherent risk with undergoing surgery or being put under anaesthetic, particularly in obese people).

* 1 in 10 chance of infection.

* 1 in 100 chance of having a blood clot; either in the legs (deep vein thrombosis) or lungs (pulmonary embolism).

* 1 in 100 chance of internal bleeding.

After the operation

* 1 in 12 chance of getting gallstones.

* 1 in 35 chance of developing an intolerance to certain foods.

* 1 in 5 chance of suffering stomal stenosis- a condition where food can get stuck in the hole connecting the stomach to the small intestine (the “stoma”). This often leads to persistent vomiting.

As well as those listed by the NHS there is also a high rate (30-70%) of nutritional deficiencies in people who have had bariatric surgery (5), which is perhaps not surprising considering the limited capacity for consuming food afterwards (see below). Although many people will not suffer from these side effects, if the number of people undergoing bariatric procedures is increased then the number of people afflicted by these conditions will also inevitably rise.

Beyond the possible negative physical outcomes there are other factors to be considered. In the first 4 weeks post-op patients are restricted to liquids and pureed foods, before building up to soft foods between 4 and 6 weeks. After 6 weeks the patient should be able to eat “normal” foods, but only in small amounts (by design the surgery results in feeling full quickly). For some people this can cause issues, as it involves a big change to their usual lifestyle; for example it has been found that peoples’ enjoyment of different foods can be significantly affected (6). Food and alcohol are also central to many social situations (particularly in the upcoming festive period!); so changes related to these things can have a knock on effect in other aspects of life. Although there is evidence for improved psychological well-being in some people for others it can be difficult to adjust to these changes, and to live up to the pre-operation expectations that undergoing the procedure will lead to a dramatic improvement all round (7).

It is important that all potential consequences are considered before any decisions are made, particularly as some of these operations are irreversible.

What are the Alternatives?

The National Institute for Health and Care Excellence (NICE) guidelines for obesity management recommend that bariatric surgery be considered for recent onset Type 2 diabetics who have a BMI of 35 or over (8). The NICE treatment pathway for type 2 diabetes however states that lifestyle modification, including education, and pharmaceutical options (9) should be explored first.

Now it is beyond the scope of this article to fully discuss the pros and cons of different forms of medication (there are plenty of reviews of pharmaceutical interventions if you’re interested, e.g. references  10-12), but lifestyle management has been shown to be effective in improving blood glucose control and reducing medication both by X-PERT (13) and by others (14-16). This in itself demonstrates that it is possible to manage this condition without resorting to surgical solutions, and should be evidence enough that surgery should be a last resort rather than a frontline solution. I can’t be the only one who thinks that we shouldn’t start cutting people up or rummaging around their innards unless there’s no other choice?

So what’s the Bottom Line?

There has been media coverage recently which could be taken to suggest that surgical interventions are the future of type 2 diabetes management. In cases where individuals have genuinely exhausted the alternatives- and are equipped physically, mentally and emotionally for the potential negative consequences of bariatric procedures- this treatment may well provide a viable solution.

There is a strong, and growing, body of evidence however showing that lifestyle management can be effective in managing- or even reversing- people’s type 2 diabetes (e.g. 17-20 and this). Lifestyle management approaches are much less severe, with fewer side effects and risks, and are potentially much less expensive*** (for any health commissioners reading). Also, contrary to some people’s beliefs, lifestyle changes don’t have to condemn you to a diet and fitness regime that is unpleasant or unsustainable! With appropriate advice and helpful guidance anyone can find an approach suitable to them (one size doesn’t fit all) without the need to end up in an operating theatre.

As with all our blogs and other work we’d love to hear your thoughts and feedback, so feel free to comment below, drop me an e-mail at sean.wheatley@xperthealth.org.uk or tweet us/me at @XPERTHealth or @SWheatley88. 

*As well as the focus on bariatric surgery over other treatments and interventions I was also slightly concerned to see a young boy’s GP approve unflinchingly of his dietary choices including extremely carb-heavy chapattis. There was also a suggestion I’m not sure I would agree with, thankfully not from a health professional, that it is essential to have Freddo’s (other chocolate bars are available) in the house as a reward for children. Perhaps when your husband is finding the chocolate bars you’ve hidden to fuel his “addiction” this is a reward the children could go without?

** Many of the studies in the first of these reviews had methodological issues. The second review meanwhile only included studies that followed participants up for a short amount of time (≤ 2 years), only included a few studies, and the studies included didn’t have many participants. Generally speaking, when it comes to research more participants is better. If you want to know more about appraising study quality we covered it in a previous blog.

*** The cost of bariatric surgery is actually suggested to be a large saving compared to the long term costs of treating and managing someone’s health (21), but it is still significantly higher than the costs associated with lifestyle change (which can be as low as £0) and there is some evidence that there may not be a real saving anyway (22).

References

1. The National Bariatric Surgery Registry. The United Kingdom National Bariatric Surgery Registry. 2015.

2. Welbourn R, le Roux CW, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery; how much should we do? BMJ. 2016;353:i1472.

3. Zhou X, Yu J, Li L, Gloy VL, Nordmann A, Tiboni M, et al. Effects of bariatric surgery on mortality, cardiovascular events, and cancer outcomes in obese patients: systematic review and meta-analysis. Obes Surg. 2016;26:2590-601.

4. Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934.

5. Kashyap SR, Gatmaitan P, Brethauer S, Schauer P. Bariatric surgery for type 2 diabetes: weighing the impact for obese patients. Cleve Clin J Med. 2010;77(7):468-76.

6. Frank S, Heinze JM, Fritsche A, Linder K, von Feilitzsch M, Königsrainer A, et al. Neuronal Food Reward Activity in Patients With Type 2 Diabetes With Improved Glycemic Control After Bariatric Surgery. Diabetes Care. 2016;39(8):1311-7.

7. Kubik JF, Gill RS, Laffin M, Karmali S. The impact of bariatric surgery on psychological health. Journal of obesity. 2013;2013:837989.

8. National Institute for Health and Care Excellence. Obesity: Identification, assessment and management. NICE Guidelines. 2014.

9. National Institute for Health and Clinical Excellence. Type 2 diabetes in adults: management. NICE guideline. nice.org.uk/guidance/ng28; December 2015.

10. Bethel MA, Xu W, Theodorakis MJ. Pharmacological interventions for preventing or delaying onset of type 2 diabetes mellitus. Diabetes, Obesity and Metabolism. 2014:n/a-n/a.</li

11. Erpeldinger S, Rehman MB, Berkhout C, Pigache C, Zerbib Y, Regnault F, et al. Efficacy and safety of insulin in type 2 diabetes: meta-analysis of randomised controlled trials. BMC Endocr Disord. 2016;16(1):39.

12. Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: A systematic review and meta-analysis. Ann Intern Med. 2016;164(11):740-51.

13.Deakin TA CJ, Williams R, Greenwood DC. Structured patient education: the diabetes X-PERT Programme makes a difference. Diabetic Medicine: 23;944-954; 2006.

14. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia. 2011;54(10):2506-14.

15. Sjöholm K, Pajunen P, Jacobson P, Karason K, Sjöström CD, Torgerson J, et al. Incidence and remission of type 2 diabetes in relation to degree of obesity at baseline and 2 year weight change: the Swedish Obese Subjects (SOS) study. Diabetologia. 2015:1-6.

16. Mark S, Du Toit S, Noakes TD, Nordli K, Coetzee D, Makin M, et al. A successful lifestyle intervention model replicated in diverse clinical settings. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. 2016;106(8):763-6.

17. Westman EC, Yancy WS, Jr., Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & metabolism. 2008;5:36.

18. Tay J, Natalie D L-M, Thompson CH, Noakes M, Buckley JD, Wittert GA, et al. A Very Low Carbohydrate, Low Saturated Fat Diet for Type 2 Diabetes Management: A Randomized Trial. Diabetes Care. 2014.

19. Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes. 2014;31(2):76-9.

20. Unwin DJ, Cuthbertson DJ, Feinman R, Sprung VS. A pilot study to explore the role of a low carbohydrate intervention to improve GGT levels and HbA1c. Diabesity in Practice. 2015;4:102-8.

21. Borisenko O, Adam D, Funch-Jensen P, Ahmed AR, Zhang R, Colpan Z, et al. Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model. Obes Surg. 2015;25:1559-68.

22. Weiner JP, Goodwin SM, Chang HY, Bolen SD, Richards TM, Johns RA, et al. Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data. JAMA surgery. 2013;148(6):555-62.

 

 

 

 

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