Weight Loss (Bariatric) Surgery and Type 2 Diabetes

Weight Loss Surgery Part 2

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There is currently a push from industry groups and others with a profit interest in weight loss (aka bariatric) surgeries (WLS) to consider them a treatment option for type 2 diabetes (T2D), and to refer higher weight patients with T2D for these procedures. In part one of this series, we discussed the basics of WLS, in this part we’ll look at the research that is used to support the push to consider these procedures as a T2D treatment. As I mentioned in part one, while I am solely responsible for the content here, my work around these surgeries has been deeply influenced and supported by the work of others, including and especially Deb Burgard and Lisa Du Breuil.

In part 1 I discussed the basics of these procedures. In this piece I’ll discuss common issues to look for in research about WLS as an intervention for T2D, and provide an deeper dive into one of the largest/most commonly cited studies used by those who support these referrals. In part 3 I’ll discuss long-term outcomes and informed consent. If you are looking for a more detailed discussion of the risks of the specific types of procedures, you’ll find that here.

Content note: There will be frank discussion of the harm inflicted by these surgeries. Also, a note that where studies are written from a perspective of weight stigma I don’t link to them, but I do provide enough information for them to be found online if someone wants to search.

Common Issues with Studies of Weight Loss (Bariatric) Surgeries as a “Treatment” for Type 2 Diabetes

Issues with Study Outcomes

Often these studies compare outcomes of WLS to outcomes of traditional medical management, specifically comparing “full remission” rates. One of the issues is that “full remission” is typically defined in these studies as HbA1c less than 6.5% without medications. The problem with this comparison is that medical management typically includes the use of medication. This means that “remission” by the study definition can be impossible to achieve using medical management. Whether intentional or by oversight, this is an extremely biased design - the study is basically designed to say [some percentage] of surgery patients achieved remission but [no or very few] traditional medical management patients did. This, then, obscures the fact that a very real question to ask patients in these situations would be “would you like to have your digestive system permanently altered into a disease state to force lifelong food restriction with the possibility of horrific side effects and death, or would you prefer to take medication?”

Issues with Traditional Medical Management

The second issue with traditional medical management is the management itself. Commonly for fat patients it is centered around weight loss, which is not just highly unlikely to be effective long-term, but can actually exacerbate blood sugar issues (through both diet behaviors and/or weight cycling.) One of the issues with weight loss as a treatment for T2D is that the food strategies that help manage blood sugar often fly in the face of what is considered “best for weight loss” (like pairing protein and/or fat with carbs to reduce blood sugar spikes, cooking techniques that create resistant starch and lower GI rather than simply telling someone to restrict carbs etc.) Fat patients, then, are often at a disadvantage in terms of medical management because the focus is on changing their body size, rather than managing their blood sugar - so everything from behaviors to pharmaceuticals are chosen based on how they are perceived to impact weight, rather than how they will likely impact blood sugar.

In this way the (well-known and predictable) failure of traditional weight loss methods is used as a justification for the surgeries, and then as proof that the surgeries are a “more effective” treatment – it’s double dipping into the same failed intervention to justify an even more dangerous intervention, at the expense of ignoring weight-neutral interventions that can provide greater benefits with far fewer risks.

Issues with ignoring adverse effects

It is a general problem in the research that side effects of the surgery tend be not tracked, poorly tracked, and/or blamed on the patient and not the procedure. Very often studies utterly fail to discuss any adverse effects of the surgeries, even though it is well known that they can have myriad negative side effects.  Dr. Paul Ernsberger and Sandy Swarzc put together a list that includes:

adhesions and polyps, massive scar tissue, advanced aging, anemia, arthritis, blackouts/fainting, bloating, body secretions (odor like rotten meat), bowel/fecal impaction, cancer (of the stomach, esophagus, pancreas, and bowel), chest pain from vomiting, circulation impairment, cold intolerance, constipation, depression, diarrhea, digestive impairment due to heavy mucus, digestive irregularities, diverticulitis, drainage problems at incision, early onset of diabetes, early onset of hypertension, electrolyte imbalance, erosion of tooth enamel, excessive dry skin, excessive stomach acid, esophageal contractions, esophageal erosion and scarring, feeling ill, gallbladder distress, gynecological complications, hair loss, hemorrhoids, hernia, hormone imbalances, impaired mobility, infection from leakage into body cavities (peritonitis), infertility, intestinal atrophy, intestinal gas, involuntary anorexia, irregular body fat distribution (lumpy body), iron deficiency, kidney impairment and failure, liver impairment and failure, loss of energy, loss of muscle control, loss of skin integrity, low hemoglobin, lowered immunity and increased susceptibility to illnesses, malfunction of the pituitary gland, muscle cramps, nausea, neural tube defects in your children, neurological impairment (nerve and brain damage), osteoporosis, pancreas impairment, pain along the left side, pain on digestion, pain on evacuation, peeling of fingernails, potassium loss, pulmonary embolus, putrid breath and stomach odor, rectal bleeding, shrinking of intestines, stomach pain, sleep irregularities, suicidal thoughts, thyroid malfunction, urinary tract infection, vitamin and mineral deficiency, vitamin and mineral malabsorption, violent hiccups that persist daily, vomiting from blockage, vomiting from drinking too fast, vomiting from eating too fast, vomiting from eating too much, and weight regain.

When studies fail to take these adverse effects into account, there is no way to tell if any benefit from the surgery was outweighed by the negative side effects of the surgery on quality of life, especially considering that many patients will regain weight back to baseline, but not the proper digestive function that the surgeries took from them.

Also, the sheer lack of long-term outcome data around adverse effects (which I’ll address further in part 3) means that even if these surgeries do improve glycemic management short-term, we literally don’t know if a patient’s long-term prognosis – including glycemic management and/or quality of life - is better or worse after having the surgery, rather than following their own path/priorities around glycemic management, even if the patient struggles with glycemic management (as many thin patients also do.)

Now let’s look at a study that I have found is very often cited by healthcare practitioners/administrators who are discussing this with me.

Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations

It appears to me that this paper’s creation was driven by those who seek to profit from the surgery, and that it was written with the goal of driving additional surgery recommendations as well as expanding insurance coverage for the procedure. I think that papers like this capitalize on widespread weight stigma (including the idea that it is worth risking higher weight patient’s lives and quality of life to make them thinner) to get buy-in from respected healthcare organizations who blindly trust those who are writing the studies. This, then, puts healthcare providers who have ethical concerns about the surgeries in a difficult position.

In this paper higher weight patients (and the people who advocate for them) are not considered  “experts” or even “stakeholders” in this process, even though they are the ones who would be risking their lives and quality of life for these surgeries.

The paper glosses over the fact that long-term outcomes are not known (using phrasing like “albeit mostly short/midterm” to describe the near complete lack of long-term outcome data.) It also uses the statement “additional studies are needed to further demonstrate long-term benefits” as if that is sufficient to ignore the lack of long-term data and recommend the surgery. I do not believe it is. I’ll also note that the phrasing above shows bias toward these procedures. Non-biased phrasing would be something like “additional studies are needed to understand long-term outcomes.”

The way in which this paper recommends higher risk interventions based on size (and not necessarily even glycemic control) is a clear indication that the recommendations here are rooted in weight stigma. Per this study:

For “class I ob*sity,” surgery should be “considered” if there is inadequate control despite optimal medical treatment either by oral or injectable medicine.

For “class II ob*sity” surgery should be “recommended” if there is inadequate control despite lifestyle and optimal medical therapy,

For “class III ob*sity” surgery should be “recommended” for every patient “regardless of the level of glycemic control or complexity of glucose-lowering regimens.”

Again, I don’t believe that these surgeries are ever ethical, but even if someone disagrees with me on that, it does not make sense from a medical (or medical ethics) standpoint that someone who has good glycemic management should be “recommended” a dangerous and expensive surgical intervention simply because their height/weight ratio is higher than a thin(ner) person with the same (or far worse) glycemic management.

In fact, even though these surgeries are being re-cast as a diabetes treatment (rather than as weight loss surgeries) we know that there are thin people who have what is considered “inadequate glycemic control with lifestyle and optimal medical treatment,” but they aren’t asked to risk these surgeries. The healthcare system is predicating risk to life and quality of life based on weight stigma rather than actual symptoms, suggesting that fat patients’ lives should be risked in an attempt at glycemic management, but thin patients’ lives should not.

In the next newsletter we’ll look at what we know (and what we don’t know) out long-term outcomes, as well as discussing the concept of informed consent as it relates to these procedures.  

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.