https://diabetes.acponline.org/archives/2016/06/10/1.htm

New clinical guidelines recommend bariatric surgery for obese patients with type 2 diabetes

Bariatric surgery should be recommended for type 2 diabetes patients with class III obesity, regardless of glycemic control, and those with class II obesity who have inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy, the guidelines said.


For the first time, clinical guidelines for the management of type 2 diabetes include recommendations for bariatric surgery in obese patients who meet certain criteria.

An international team of 48 clinicians and scholars developed the evidence-based treatment algorithm for type 2 diabetes at the second Diabetes Surgery Summit, held in 2015 in London. The guidelines, which have been endorsed by 45 professional societies, were published online on May 24 by Diabetes Care.

Although obesity guidelines recommend bariatric surgery in patients with type 2 diabetes, diabetes guidelines have previously offered little mention of surgery. The new guidelines cite a mounting body of evidence suggesting that bariatric (or metabolic) surgery provides better glycemic control and reduction of cardiovascular risk factors in obese patients with type 2 diabetes than various medical and lifestyle interventions.

The updated guidelines are summarized as follows.

  • Metabolic surgery should be recommended as an option to treat type 2 diabetes in appropriate surgical candidates with class III obesity (body mass index [BMI] ≥40 kg/m2), regardless of the level of glycemic control or complexity of glucose-lowering regimens.
  • Metabolic surgery should also be recommended to patients with class II obesity (BMI, 35.0 to 39.9 kg/m2) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy.
  • Metabolic surgery should also be considered as an option to treat type 2 diabetes in patients with class I obesity (BMI, 30.0 to 34.9 kg/m2) and inadequately controlled hyperglycemia despite optimal medical treatment by either oral or injectable medications (including insulin).
  • All BMI thresholds should be adjusted for the patient's ancestry. For example, BMI values should be reduced by 2.5 kg/m2 for patients of Asian descent.
  • High-volume centers with multidisciplinary teams that understand and are experienced in diabetes management and gastrointestinal surgery should be the ones to perform these surgical interventions.
  • Clinicians should follow current guidelines for postoperative support after metabolic surgery (e.g., ongoing and long-term monitoring of micronutrient status, nutritional supplementation).
  • Recognizing metabolic surgery as a potentially cost-effective treatment option for obese patients with type 2 diabetes, the clinical community should work with health care regulators to introduce appropriate reimbursement policies.
  • The choice of the appropriate surgical procedure should be based on an evaluation of the risk-to-benefit ratio in individual patients. Clinicians should weigh long-term nutritional risks versus effectiveness on glycemic control and cardiovascular disease risk.