Metabolic Surgery for Diabetes

India has come to be known as the diabetic capital of the world. With increasing urbanization, and a population that has crossed more than 1 billion, the greatest challenge that India faces today is the steep rise in noncommunicable diseases, especially type 2 diabetes mellitus (T2DM) and obesity.


The reason for this high incidence of type 2 diabetes among Indians can be attributed to greater body fat percentage and visceral or abdominal obesity. At the same BMI levels, Asians tend to have much higher body fat percentage as compared to their western counterparts. This is also genetic in part and the presence of “thrifty” gene has become a curse in these times of surplus. Some aspects of maternal nutritional intake during pregnancy, along with low birth weights of the new born babies can also lead to an increased predisposition for developing insulin resistance, even as early as 8 years of age.


It is widely known that the risk of the metabolic syndrome in Asians starts at relatively lower body mass index (BMI) levels (22–23 kg/m2). This is primarily due to higher body fat percentage. It can well be deduced that Asians develop type 2 diabetes at a much lesser degree of obesity, younger age and tend to experience complications longer.


Results from Screening India’s Twin Epidemic (SITE) study revealed that 34.7% of all patients screened had type 2 diabetes and one out of five patients had both, type 2 diabetes and hypertension. When we include the numbers of those who are prediabetic and those with undiagnosed diabetes, it is obvious that the Asian growth story is bound to be greatly affected by this looming epidemic of T2DM.


The current treatment modalities for type 2 diabetes are ineffective in achieving good glycemic control in most patients. Lifestyle modification and medication remain the mainstays of therapy for the control of type 2 diabetes; however, the goals of diabetes remission or control are difficult to achieve. Only 7.3% of all patients achieve adequate glycaemic control with medical treatment.


There has been a great impetus in research for a cure of type 2 diabetes. Despite the infusion of millions of dollars worldwide, researchers have failed to find the answer that could stall the progression of this disease and decrease the burden of the micro and macrovascular complications associated with T2DM. Over the years, strong evidence of improvement in type 2 diabetes and impaired glucose tolerance in obese patients with diabetes (BMI > 35 kg/m2) has been achieved with all types of bariatric surgery.


Bariatric surgery was recognized as an effective treatment option for obese patients with type 2 diabetes by the American Diabetes Association in 2009. In September 2015, diabetic federations from world over came together in the second diabetes surgery summit and laid down the guidelines for metabolic surgery for diabetes. This is now commonly known as metabolic surgery for diabetes.These are listed as under:



Predictors of remission after metabolic surgery for diabetes


Predictors for remission after metabolic surgery for diabetes include:

  • Age- Younger patients tend to get better results after metabolic surgery for diabetes.
  • BMI- Higher the BMI better the remission of type 2 diabetes
  • C-peptide levels- These reflect the status of pancreatic function and patients with c-peptide levels more than 2 get better results in terms of diabetes remission.
  • Duration of diabetes- This is the most important factor. Shorter the duration of diabetes better the results for remission.
  • Insulin use- Insulin use is a negative marker for remission. Patients who are not on insulin yet, tend to get better results in terms of diabetes remission.


Mechanisms of remission of diabetes after metabolic surgery

Metabolic surgery for type 2 diabetes functions on the basis of either weight dependent or weight independent mechanisms.

Weight dependent mechanisms are:

  • Restriction of calories post surgery.
  • Loss of weight that leads to a decrease in insulin resistance

As the remission of type 2 diabetes after metabolic surgery is quite rapid, it suggests that there may be certain weight independent mechanisms as well. These are mentioned as under:

  • Rapid passage of food into the small intestine leads to early release of certain gut hormones like GLP1 and PYY. These helps to improve type 2 diabetes after surgery.
  • Role of bile acids
  • Role of gut flora

Metabolic surgery for diabetes has given hope to many obese diabetics who have been struggling not only with their weight but also for control of type 2 diabetes. It has been seen that surgery actually turns out to be a more cost-effective option in the long term as compared to medical treatment alone. Metabolic surgery for diabetes cost may seem to be higher at one go but the surgery ends in recovering its cost in the first 6 years. Metabolic surgery for type 2 diabetes cost depends on many factors. Cost of metabolic surgery for diabetes depends on the duration of surgery, type of procedure performed and the equipment used etc. Cost of metabolic surgery for type 2 diabetes also depends on the duration of hospital stay. The cost will be explained to you in detail by the team during the consult.