Everything to know before you start

More healthcare providers are recommending the use of medical intervention for weight loss. Read on and be ready for that conversation

More than 60 per cent of Australian adults are overweight or obese. As this number continues to skyrocket, so does the number of people developing type 2 diabetes and other diseases related to excess weight.

Experts routinely advise overweight and obese people with type 2 diabetes to lose weight. Shedding a few kilos

– or more – can improve your condition significantly.

But increasingly, some experts recommend weight-loss surgeries – called metabolic and bariatric surgeries in medical parlance – to achieve weight loss and glucose control if other strategies aren’t working. This field is evolving fast.

But it’s no quick fix. Let’s talk through the options, and the risks and benefits, to consider for each type of procedure.

Surgeries and procedures

According to the American Society for Metabolic and Bariatric Surgery (ASMBS) – similar results have been seen in other global studies – surgery can improve type 2 diabetes in 90 per cent of patients and cause remission of type 2 in 78 per cent of them. (Remission occurs when a person can maintain normal

blood glucose levels without taking medications.)

In fact, weight-loss surgery is now considered a standard treatment option for people with type 2 diabetes, based on a statement of 45 professional organisations from around the world, including the American Diabetes Association (ADA), the International Diabetes Federation, and Diabetes UK. In June 2016, the ADA’s journal, Diabetes Care, published the first clinical guidelines for weight-loss surgery as a treatment for people with type 2 diabetes.

Definitions for the most common bariatric and metabolic surgeries and procedures follow.

• Intragastric balloon, has been used for over 20 years and inserts an uninflated silicone balloon into the stomach, which is filled with saline to limit how much you eat, and also delays gastric emptying. The balloon is not as invasive as some, but is a temporary measure that can come with some early side-effects (24-36 hours) of nausea and vomiting. “Gastric balloon intervention should be seen as a set of training wheels to support significant weight loss while changing lifestyle,” says Dr Adrian Sartoretto of Sydney’s Bariatric and Metabolic Institute and BMI Clinic. “As with any weight loss, longer-term lifestyle changes are required to maintain the loss.”

• Endoscopic sleeve gastroplasty (ESG) is a relatively new procedure, which is performed endoscopically (through the mouth) without the need for surgery. Similar to the sleeve gastrectomy (but without removing the stomach permanently), the stomach’s volume is reduced, limiting the food intake. As the procedure is less invasive than surgical options it is considered to be a safer option. “Our patients choose the ESG due to the safety and efficacy profile, and also the minimal down-time required,” says Dr Sartoretto.

• Gastric (lap) band surgery involves putting a band around the upper part of the stomach. This simpler surgical procedure tends to be less effective for weight loss and diabetes remission than gastric bypass.

• Laparoscopic sleeve gastrectomy, involves the stomach being stapled in two sections, with the larger amount being permanently removed. The procedure is less complicated and has fewer complications than the gastric bypass, but it may not be as effective at inducing remission of diabetes, says ASMBS former president Raul Rosenthal.

• Roux-en-Y gastric bypass procedure restructures the pathway for food through your body so it will bypass most of the stomach and the upper part of the small intestine.

Considerations

Bariatric and metabolic surgeries have become more common, given their success rates in helping people lose weight and improve their diabetes. For some morbidly obese people with diabetes, surgery is the best option.

But research is beginning to show it could also help people with prediabetes or type 2 diabetes in less dire circumstances.

In fact, these procedures and surgeries may be offered to more people in the future, says Suneil Koliwad, assistant professor at the Diabetes Center at the University of California.

Obese people are experiencing improvements in blood glucose control right after surgery (some even in the hospital, but many in the first week or two), long before they lose significant weight. This suggests that the surgery itself, not just the subsequent weight loss, can help people with their diabetes.

Some experts now suggest people with diabetes could still benefit from the surgery’s effect on their blood sugar levels, even if they don’t meet the obesity requirements currently recommended for surgery. So those requirements may change.

“It’s not there yet, but it’s on the horizon,” Koliwad says.

At present, most insurers require people to have a BMI of 40, or a BMI of 35 plus obesity-related conditions such as type 2 diabetes, before they cover the surgery. Ask your insurer about specifics.

Donna Ryan, associate editor-in-chief of the journal Obesity, agrees that there will probably be more surgeries in the future for people with diabetes. “There’s a movement toward using BMI as a screener, and then identifying people with metabolic problems and using weight loss as a pathway to improvement,” she says.

Despite a growing number of success stories, there’s not yet a standardised method for reporting outcomes for bariatric and metabolic surgeries, which makes it challenging to track success on a long-term basis. So consult carefully with your health-care provider and thoroughly discuss all the risks, as well as the benefits, before you schedule any type of surgery or procedure.

How to prepare for a procedure

Prior to surgery it is important to focus on the new lifestyle ahead of you. The best place to start is to change your diet. Although it may be tempting to binge eat one last time before your ‘new body’, the sooner you prepare your body for the change, the quicker you will be able to adapt after the surgery.

Also, experiment with protein powders to discover which flavours you enjoy – as well as low-calorie, protein-rich foods – as you will be on a meal replacement both pre- and post-procedure to allow your body to heal.

Ensure you have spoken to your surgeon about what the surgery entails to ease any anxiety, and talk to your support group – make sure your immediate friends and family understand what your needs will be in order to heal and pull through on the other side.

After the surgery, you will be rapidly losing weight, so ensure you have comfortable and loose clothes for your transition, and pack some of these in your hospital bag. Also, stop smoking prior to surgery.

It is important to recover and gain plenty of rest within the first few weeks. However, it is also important to avoid infection, and to get up and walk as much as you can, comfortably, to begin building up your strength.

Walking helps to prevent blood clots, but take it slowly!

Follow your surgeon’s instructions on how long you need to stay on a liquid diet, and when you can transfer to pureed foods and further soft foods.

With some procedures, it can take more than a month before you can begin eating soft foods and resuming normal activities. Before you start any physical activity or a new exercise program, consult your surgeon or clinic.