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Bariatric Surgery for Treating Type 2 Diabetes

Online Health Chat with Bariatric Surgeon Tomasz Rogula, MD, PhD, and Endocrinologist and Diabetes Specialist Sangeeta Kashyap, MD

June 28, 2012

Introduction

Cleveland_Clinic_Host: If you struggle with diabetes and are overweight, you are not alone. More than half of Americans are overweight and roughly 12 million have severe obesity. Obesity is one of the most important factors for the development of type 2 diabetes. Recent studies have shown that bariatric surgery (also known as gastric bypass or weight-loss surgery) is not only an effective tool for treating obesity, but also for preventing, treating and even resolving diabetes in some cases.


For More Information

The Cleveland Clinic Bariatric and Metabolic Institute works closely with Cleveland Clinic endocrinologists to treat patients with diabetes and develop a program tailored to suit their needs.  Our endocrinology program is ranked in the top 10 nationally by U.S.News & World Report.

For Appointments

To make an appointment with Dr. Tomasz Rogula, or any of the other specialists in the Bariatric & Metabolic Institute at Cleveland Clinic, please call 216.445.2224 or call toll-free at 800.223.2273, ext. 52224.  You can also visit us online at www.clevelandclinic.org/bariatric .


About the Speakers

Tomasz Rogula MD, PhD, is a Staff Surgeon and Assistant Professor of Surgery at Cleveland Clinic’s Bariatric & Metabolic Institute and the Department of Surgery. In addition to bariatric surgery, his specialty interests include advanced laparoscopic and robotic surgery, gastrointestinal surgery and hernia repair. He performed the first robotic-assisted gastric bypass for obesity, and initiated single incision laparoscopic cholecystectomy and hernia repair at the Cleveland Clinic. Dr. Rogula has pioneered research on novel weight-loss surgery procedures, and has published articles and book chapters on bariatric and laparoscopic surgery. He is a member of the American Medical Association, Society of American Gastrointestinal Endoscopic Surgeons, American Society for Metabolic and Bariatric Surgery, International Federation for the Surgery of Obesity and Metabolic Disorders, and European Association for Endoscopic Surgery. Dr. Rogula is a co-founder of the International Club of Young Laparoscopic Surgeons and the founder and president of the International Bariatric Club—a global bariatric network organization. He was awarded for his medical innovations and holds pending patents for new surgical devices.

Sangeeta Rao Kashyap MD, is a staff physician in Cleveland Clinic’s Endocrinology & Metabolism Institute. She is also Assistant Professor of Medicine at Cleveland Clinic’s Lerner College of Medicine. She is certified by the American Board of Internal Medicine. She completed a fellowship in endocrinology, diabetes and metabolism at the VA Greater Los Angeles Healthcare System/University of California Los Angeles (UCLA) and a postgraduate research fellowship in diabetes at the University of Texas Health Science Center at San Antonio, San Antonio, Tex. Her research interests include insulin resistance and the metabolic syndrome, and metabolic effects of bariatric surgery.  She is a recipient of a research grant from the American Diabetes Association and the National Institute of Health, and one of the overseeing physicians on the recent STAMPEDE II study which looked at the effect of bariatric surgery in curbing type 2 diabetes.


Let’s Chat About Bariatric Surgery

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic experts Dr. Thomas Rogula and Dr. Sangetta Kashyap. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.

Bariatric Surgery and Type 2 Diabetes
penn3: How likely is it that bariatric surgery will help cure my type 2 diabetes?
Dr__Rogula: Very likely. About 80 percent of patients have their diabetes resolved, but the likelihood of that depends on how long did you have diabetes and if you are using insulin.

vrow: If I have type 2 diabetes, should I prepare for bariatric surgery differently?
Dr__Kashyap: You may need some adjustment of your diabetes medications prior to surgery. Also, if you are on a liquid diet prior to surgery to prevent low sugars.

joto: Will my diabetes go away permanently, or is this fix only temporary?
Dr__Kashyap: Your diabetes will definitely improve, but it’s not certain if your diabetes will be cured.

grt3: How can I find out if I am a candidate for bariatric surgery if I have type 2 diabetes?
Dr__Kashyap: Know what your body mass index is and check with your insurance carrier.

 

Signs and Symptoms of Type 2 Diabetes
apples: What are the main symptoms of type 2 diabetes?
Dr__Kashyap: Many times no symptoms are present, but in cases of severe hyperglycemia, there may be fatigue, polyurea and thirst.

howdy: I saw the term diabetes type 1.5. What does this mean?
Dr__Kashyap: That means there is some resistance, but the primary defect is that the pancreas won't make insulin.

kait: I read about a study showing that poor glucose management with diabetes is linked to reduced mental functions in older people. Can you please elaborate? Is this a serious issue?
Dr__Kashyap: High blood sugars and diabetes are linked to a decline in cognitive function. Other factors like blood pressure and obesity also play a role in this process

wllm5: What is hemoglobin A1c, and why should I care about it?
Dr__Kashyap: It is a marker of the average blood sugar in the body for the last three months.

 

Risk Factors for Type 2 Diabetes
honey2: What types of things makes a person more likely to develop type 2 diabetes?
Dr__Kashyap: A family history of diabetes, being overweight, sedentary lifestyle, smoking, and a high fat/sugar diet.

who_r_u: If I am considered overweight or obese, is it inevitable that I will develop diabetes?
Dr__Kashyap: Not always—being overweight is a big risk factor that increases the risk of diabetes and is an acquired risk factor, but family history and genetics are equally as important.

veel98: I heard about a new study showing that psoriasis is an independent risk factor for diabetes. I don’t get the correlation. Can you please explain? How serious is it of a risk?
Dr__Kashyap: That is correct that there is an association, but the etiology is not known. Prevention with healthy diet and exercise are the key to preventing diabetes in high risk people.

 

Prognosis of Type 2 Diabetes
darcyp: I was diagnosed with type 2 diabetes mellitus less than one year ago, does that improve the likelihood?
Dr__Kashyap: Early onset of type 2 diabetes is very treatable with diet, exercise and sometimes oral agents like metformin.

open_up: I read that type 1 or type 2 diabetics can start to develop the other form, thereby, causing the patient to have both type I and type 2 diabetes together. I did not know this was possible and I don't quite understand it. How dangerous is this and how is it treated (any differently)?
Dr__Kashyap: Both types of diabetes are linked to inadequate insulin production. Weight gain can complicate both types of diabetes and make it harder to control.

 

Lifestyle Changes to Prevent or Treat Diabetes
retal: How does losing weight alone control/prevent/treat diabetes?
Dr__Kashyap: Weight loss improves insulin sensitivity and can make your pancreas work again. Bariatric surgery also improves gut hormones that make your pancreas work to make insulin again. These hormones are also the key to why bariatric surgery improves diabetes.

arcadia: If I have diabetes, can I still go on a diet?
Dr__Kashyap: Yes, but you need to have your medication adjusted to prevent low sugars. It depends on your medicines.

legions: If I have diabetes, which way is the healthiest to lose weight—surgery or dieting?
Dr__Kashyap: The safest is diet, but is not as effective as surgery. Surgery is riskier and should be done in a high volume center by experienced surgeons.

grollo: Sugar substitutes give me headaches. What can I use instead?
Dr__Kashyap: That can happen. Avoid sugar substitutes if this occurs.

cree: Why is dextrose or glucose recommended over the readily available sucrose (table sugar) for treating a hypoglycemic situation?
Dr__Kashyap: Both work to bring up the sugar. We recommend candy or some juice.

goblo: Any advances in noninvasive CGMs (continuous glucose monitors)?
Dr__Kashyap: The technology is improving and can help those who are unaware of hypoglycemia in type 1 diabetics.

 

Bariatric Surgery For Weight Loss
judy: Why does the bypass stomach have to be made so small?
Dr__Rogula: It is for better weight loss, also for decreasing ulcer formation and reflux.

ho_ho_ho: Do you have to be obese to get surgery?
Dr__Rogula: Currently, most insurance carriers cover bariatric surgery in patients with BMI greater than 35, so, yes, you need to be obese.

value: What are the criteria that make someone a candidate for bariatric surgery?
Dr__Rogula: BMI greater than 35 plus major comorbidities, like diabetes, hypertension, heart problems; or BMI greater than 40 without major comorbidities.

grt3: Regarding your answer to my previous question, is candidacy for surgery is based solely on BMI (body mass index)?
Dr__Rogula: In addition to BMI, you should have major comorbidities related to obesity, like diabetes, hypertension, heart problems, etc. For patient with a BMI greater than 40, no major comorbidities are needed to have their surgery covered.

 

What to Expect After Bariatric Surgery
chloe: What is the recovery time after surgery?
Dr__Rogula: Most patients spend two to three days in the hospital, and then need about two to three weeks afterward to fully recover and return to work.

horace: How soon can I expect to start losing weight after I receive surgery?
Dr__Rogula: Weight loss starts immediately after surgery, and typically continues up to two years after.

10goll: Is bloating common with eating after the surgery?
Dr__Rogula: After some procedures, it happens. Please work with your nutritionist to avoid certain foods causing bloating.

kupferod: What about the recent Lap-Band® controversy? How would a patient rule out an unfit facility or doctor?
Dr__Rogula: Resent research showed some poorer results of long-term weight loss after Lap-Band®. The best way to verify doctor's qualifications is to contact the American Society for Bariatric and Metabolic Surgery (ASMBS).

katarina: What kinds of results should I expect from bariatric surgery?
Dr__Rogula: Depending on which procedure you choose, the weight loss is about 100 lbs within one year. Most of the obesity-related health problems should resolve, including diabetes and hypertension.

rock_on: How long after bariatric surgery will I start seeing improvements in my diabetes?
Dr__Kashyap: Within days to weeks, typically. Your caloric intake is reduced and weight loss will occur at the same time that good gut hormones are released, helping your pancreas to make insulin again.

quest: I have GERD (gastroesophageal reflux disease). How does this surgery affect this?
Dr__Rogula: Most patients improve their GERD symptoms significantly after surgery, especially after gastric bypass.

 

Lifestyle After Surgery
kupferod: What are the lifestyle changes necessary post-procedure? Will your doctor discuss these in-depth and help plan with you?
Dr__Rogula: Yes, you need to follow our recommendation regarding your diet, exercise and vitamins and supplements. We offer very extensive preoperative and postoperative consultations with nutritionists and a psychologist, who provide good support to the patient.

oh_god: Are you still on a ‘diabetic’ diet, even after the surgery?
Dr__Kashyap: Yes. Your diabetes will be diet controlled after surgery. You should still be checked periodically for diabetes complications and progression even after bariatric surgery.

work_for_it: What are the ‘rules’ on alcohol after surgery?
Dr__Rogula: Even a small amount of alcohol may have harmful effects. Please avoid alcohol. It is very rapidly absorbed to the intestine, and ‘works’ much faster then before surgery.

help_out: Are you still on insulin after the surgery?
Dr__Kashyap: Sometimes yes, but it will be weaned off if you don't need it.

oh_wine: Are there limitations to taking certain medications after surgery?
Dr__Kashyap: Yes. Certain drugs are absorbed differently by the body after surgery because your gut is altered

kupferod: What about the risk of developing an alcohol addiction post-procedure? Have you seen this in any of your patients?
Dr__Kashyap: A person is more prone to the effects of alcohol after stomach reduction surgery. We recommend limiting alcohol intake after surgery.

kupferod: Do you recommend any psychological counseling post-procedure?
Dr__Kashyap: Yes. Some people need psychological counseling for behavior modification regarding diet, alcohol use, mood control, etc.

Long-term Results of Bariatric Surgery
survivor: Are there studies about health and eating issues five to 10 to15 years after gastric bypass, especially if partial or more weight has been regained?
Dr__Rogula: That depends on what procedure you had. Some procedures used in the past resulted in some weight regain. To maintain good results, you should follow recommendations for good eating habits and exercise.

survivor: What happens to a person who starts regaining weight after the surgery? Are there complications associated with this?
Dr__Rogula: Please see your surgeon to evaluate this. In most cases, it is due to poor eating habits and lack of exercise. In some cases, it may be caused by some stretching out of the pouch.

Risks of Bariatric Surgery
greely: What are the mortality statistics for bariatric surgery procedures?
Dr__Rogula: Mortality from bariatric surgery is very close to zero. Very few patients experience major complications. Mortality mainly depends on type of surgery. For example, for gastric bypass surgery it is about 0.2 percent

kupferod: What are the inherent risks, if any, of bariatric surgery?
Dr__Rogula: It all depends on the type of surgery. For example, a major risk of gastric bypass is intestinal leak which leads to internal infections. The major risk of gastric banding is gastric reflux and slippage of the stomach. In general, the overall risk of bariatric surgery is about 5 percent for major complications.

cobra: All of the literature claims that slow weight loss is best, both for long term success and health. How can such rapid weight loss as seen with this surgery be healthy?
Dr__Kashyap: Rapid weight loss results in fat and lean muscle loss. When it occurs in the presence of exercise and adequate protein intake to maintain muscle mass, is not necessarily harmful.

brrr: What types of complications might occur after I receive bariatric surgery?
Dr__Rogula: That depends on what type of surgery you choose. Gastric bypass has more risks, but, even still, less then 5 percent patients may develop major complications. The most severe complication —intestinal leak —occurs in less than 2 percent of patients.

Insurance Coverage of Bariatric Surgery
tda: I have type 2 diabetes. Will insurance cover the cost of having bariatric surgery?
Dr__Rogula: Your insurance should review that request. In general, if the BMI (body mass index) is greater than 35 and if there are major comorbidities, including diabetes, it is covered.

mini_me: If you can get your insurance to pay for this surgery, do they also cover other surgeries after the weight loss? Such as those dealing with excess baggy skin?
Dr__Kashyap: Not always, as this is considered cosmetic by some insurance companies.

Weight Loss Before Surgery
glow_stick: A friend of mine had the surgery and had to lose weight prior to the surgery. This was very hard for her. Why did she have to do this?
Dr__Kashyap: To make sure that she can stick to a diet program. Weight loss prior to surgery can reduce liver fat, so that the operation is technically easier to perform.

Weight Loss Medications
carly: Can you talk about the new drug, Belviq™, approved by the FDA recently? How does it work? Do you know where it is being prescribed?
Dr__Rogula: Please set up an appointment with our bariatric medicine specialists to have this medication prescribed. We have limited experience with this particular medication. Overall, very few medications are proven to be effective.

New Devices in Bariatric Surgery
JMcK: What potential do minimally invasive treatment options, such as the GI Dynamics EndoBarrier® device, have on the resolution of type 2 diabetes and obesity? And how long will these devices need to reside in the body to attain clinically useful results?
Dr__Rogula: We are currently investigating these new devices. FDA has not approved them yet for clinical use. There are preliminary data from overseas showing quite good results, but it is too early to say that it will work long term. Please stay in touch with Cleveland Clinic’s Bariatric & Metabolic Institute for updates.


Closing

Cleveland_Clinic_Host: We have exhausted all of your questions. I’m sorry to say that our time with Cleveland Clinic experts Dr. Thomas Rogula and Dr. Sangetta Kashyap is now over. Thank you, doctors for taking your time to answer our questions today about bariatric surgery for treating type 2 diabetes.

Dr__Rogula: Thank you for all interesting questions. Please consider seeing us in person for individual consultation if you consider bariatric surgery.

Dr__Kashyap: Thank you for having me.


More Information

To make an appointment with Dr. Tomasz Rogula, or any of the other specialists in Cleveland Clinic’s Bariatric & Metabolic Institute, please call 216.445.2224 or call toll-free at 800.223.2273, ext. 52224.  You can also visit us online at www.clevelandclinic.org/bariatric.

To make an appointment with Dr. Sangeeta Kashyap, or any of the other specialists in the Cleveland Clinic’s Endocrinology & Metabolism Institute, please call 216.444.6568 or toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology .

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult

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