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Bariatric Surgery: An Option for Obese Type 1 Diabetes?
February 21, 2014 (Medscape) — In a small study, 10 severely obese patients with uncontrolled type 1 diabetes who underwent bariatric surgery not only shed pounds, they also had improved glycemic control and a better metabolic profile 3 years later. The results were published online February 20 in a letter to the editor in Diabetes Care.
On average, the patients had a body mass index (BMI) of 41.6 at the time of surgery, which dropped by 27% following the operation and was accompanied by a mean fall in HbA 1c levels from 10.0% to 8.9%. The weight loss was "remarkable and sustained," note the authors, led by Stacy A. Brethauer, MD, from Cleveland Clinic, Ohio.
Dr. Brethauer told Medscape Medical News that physicians may be reluctant to refer obese patients with type 1 diabetes for bariatric surgery, "because of the thought that maybe it wouldn't help — there's just going to be no chance their pancreas will recover." But "what this paper shows is that some patients with type 1 diabetes would benefit from these operations — [not just] in terms of their quality of life but also their glucose control," he added.
"It's a small study with limited experience, but we hope that it will generate discussion and further research in this patient population," he said.
Bariatric Surgery in Type 1 vs Type 2 Diabetes
Patients with type 2 diabetes typically develop worsening insulin resistance with weight gain, in a long, slow process, and a growing body of evidence suggests that some of these individuals can achieve diabetes remission after losing weight with bariatric surgery, Dr. Brethauer noted.
Those with type 1 diabetes may also become obese, and although they may not achieve diabetes remission, they might require less insulin therapy after bariatric surgery, he explained.
Fewer than 10 cases of type 1 diabetic patients who've had bariatric surgery have been published, but in all instances they lost a significant amount of weight and improved their glucose control.
In this series, Dr. Brethauer and colleagues examined clinical outcomes and metabolic parameters in morbidly obese individuals with uncontrolled type 1 diabetes who had undergone bariatric surgery at their center from 2005 to 2012.
At the time of their surgery, the 9 women and 1 man had a mean age of 45.6 years, had had type 1 diabetes for a median of 22 years, and had an average of 10 comorbidities, including cardiovascular disease, sleep apnea, gastroesophageal reflux, hypertension, and hyperlipidemia.
Seven patients underwent laparoscopic Roux-en-Y gastric bypass, 2 patients had adjustable gastric banding, and 1 patient had a sleeve gastrectomy.
At a mean follow-up of 36.8 months, 9 of the patients had lost more than 60% of their weight. On average, the patient's daily insulin requirement dropped from 0.74 to 0.40 U/kg/day.
Average LDL cholesterol also dropped by 23.0 mg/dL, HDL cholesterol increased by 10.8 mg/dL, and triglycerides dropped by 30.5 mg/dL — all significant changes.
Hypertension resolved or improved in 5 of the 7 hypertensive patients, and albuminuria resolved in 1 of the 2 patients with microalbuminuria.
"The findings of this study, which is the largest case series to date, indicate that bariatric surgery leads to a remarkable and sustained weight loss in severely obese patients with type 1 diabetes and results in significant improvement in their glycemic status and comorbid conditions," the authors summarize.
"Longer follow-up studies in a larger cohort" are required, they conclude.