Diabetes and Weight-Loss Surgery: The 4 Types of Procedures, Pros, and Cons
Being overweight is a two-edged sword: it hits us physically and emotionally. Those carrying extra weight are often blamed for it, and while lifestyle intervention programs can be an effective means of weight loss, they rarely lead to long-term weight loss. Lifestyle intervention programs have around a 95 percent failure rate. Meanwhile, over 400,000 people pass away from obesity-related causes in the US every year.
The direct links between obesity, reduced lifespan, and type 2 diabetes are encouraging some doctors to think of obesity like any other disease. Like any disease, obesity has known causes and symptoms and causes functional changes that damage health. But the causes of obesity are complex: emotional, socioeconomic, genetic, and environment factors come into play and are often hard to address medically. Despite the serious health risks of obesity, treatment options remain less than ideal.
Bariatric, or weight-loss, surgery is effective in decreasing diabetes-related deaths and improving diabetes control on a long-term basis, and most people who undergo weight-loss surgery are able to lose significant amounts of weight and keep it off long-term. In some studies, surgery led to partial or complete diabetes remission in two-thirds of patients. Below we’ll discuss the four types of weight-loss surgery and their benefits and risks.
Laparoscopic Adjustable Gastric Banding (LAGB)
This procedure is sometimes referred to as lap-band surgery and was first used in the mid-1990s. It involves surgeons making a small incision in the upper abdomen and inserting an adjustable band around the upper part of the stomach. The band creates a smaller stomach pouch at the top of the stomach that will fill quickly, allowing the patient to feel full after eating less. The band will allow food to slowly pass through the pouch area into the main part of the stomach.
The band can be adjusted via a balloon placed around that band that can be filled with more or less fluid for a tighter or looser fit, and fluid level is adjusted through a small port placed under the skin of the belly. This surgery leads to diabetes remission in 45 to 60 percent of patients, though diabetes remission is tied to the success of patient weight loss.
Roux-en-Y Gastric Bypass (RYGB)
RYGB surgery works by reducing the size of a patient’s stomach to that of about an egg. The upper section of the stomach is stapled off, creating a smaller stomach pouch that is then attached to the Roux limb of the small intestine. This means that ingested food bypasses most of the stomach and the first part of the small intestine. Fewer calories can be absorbed because of the bypassed elements of the digestive tract, leading to weight loss.
This surgery can potentially help someone lose 100 pounds of extra weight and causes type 2 diabetes remission in about 80 percent of patients. It can also cause improvements in blood pressure, heart disease, and sleep apnea.
Biliopancreatic Diversion (BPD) or Sleeve Gastrectomy
A BPD procedure, or sleeve gastrectomy, removes a horizontal portion of the stomach so that the stomach is the same width but much narrower. The smaller stomach area means that a person will feel fuller faster and can change gut hormones to improve diabetes. Diabetes remission rates after sleeve gastrectomy are about 60 percent.
Duodenal Switch (Sometimes Combined with Sleeve Gastrectomy)
This procedure can be done on its own or in combination with a sleeve gastrectomy. It involves re-attaching the first part of the small intestine, near the stomach, to the latter part of the intestine so that food bypasses much of the small intestine and fewer calories and nutrients are absorbed. This procedure is more complex and comes with greater risks, but it is the most effective procedure for causing lasting improvement or remission in type 2 diabetes. More than 85 percent of patients who undergo a duodenal switch reverse their diabetes.
Weight-Loss Surgery Risks
Generally, these surgeries are laparoscopic procedures that are performed with small surgical tools inserted through small incisions. They are done while the patient is done under general anesthesia and usually have low complication rates.
A small percentage of patients who undergo LAGB procedures do not have changes in their hunger and do not experience long-term weight loss. All weight-loss surgeries may require revisions, and complication risk increases if patients do not follow their eating plan. The most common complications are dumping syndrome (which occurs when food passes to quickly from the stomach to the small intestine causing cramps and gastrointestinal distress), nutritional deficiencies, loss of bone density, and abdominal pain.
Surgeries may cause bleeding, infections, or blood clots in the legs. General anesthesia may cause breathing problems or other negative reactions in some patients. Surgeries may cause leaks that need to be corrected, and the band in LAGB procedures may slip. In all procedures, if patients do not eat right, they may regain weight.
Because diabetes can cause wounds to heal more slowly, those with diabetes considering weight-loss surgery may be at increased risk of complications, but at the same time people with type 2 may stand to gain the most from weight-loss surgery. Patients considering weight-loss surgery should discuss all the pros and cons, including all possible complications, with their doctor.
The American Diabetes Association’s 2018 Standards of Medical Care recommend weight-loss surgery for people with a body mass index (BMI) of 40 or higher (37.5 for Asian Americans) regardless of blood sugar level, and for people with a BMI between 35 and 39 (32.5 and 37.4 for Asian Americans) where blood sugar is high. In some cases, people with a lower BMI may be eligible if medications fail to properly control blood sugar.
Potential candidates should remember that their appetite may return six months to two years after surgery, and they will need to adopt healthy eating to avoid regaining weight. Also, dramatic weight loss often occurs immediately after surgery but tapers off in later months, and patients may not lose as much weight as they had hoped. Surgery should be delayed until substance abuse, depression, and mental health have all been adequately addressed.
Weight-loss surgery is a big decision, and if successful can lead to dramatic, long-term weight loss, improved type 2 diabetes control, and improved quality of life. It’s certainly not the right choice for everyone, but it should also not be considered the easy way out or even “cheating” considering the many factors that lead to obesity and the serious health consequences of the condition.