Can Gastric Bypass Surgery Cause Remission in Type 2 Diabetes?

Curated by Claudia Shannon / Research Scientist / ishonest

If 75 percent of the obese patients with type 2 diabetes achieved remission after gastric bypass surgery, would you say it sounds too good to be true?

The study focused on the effects of RYGB on diabetes remission, predicting factors, likelihood of relapse, surgical complications, and incidence of microvascular (retinopathy, neuropathy, etc.) and macrovascular (clogged arteries) complications.

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The claim of diabetes remission, however, gives some diabetes health practitioners cause for concern.

The Roux-en-Y gastric bypass is one of many weight-loss surgery options available today. It consists of two components, explains the American Society for Metabolic and Bariatric Surgery (ASMBS).

The surgery reduces the size of the stomach by dividing the top of the stomach from the rest of the stomach. The first section of the small intestines is also divided and essentially shortened, then reconnected to the smaller pouch of the stomach.

The result is that patients become limited in how many calories they can consume in one sitting and over the source of the day. Overeating results in pain, vomiting, and a significant degree of discomfort.

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Patients also lose weight because the entire digestive system is now absorbing fewer calories — which means fewer vitamins and minerals, too.

The ASMBS adds, “Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.”

How remission is achieved

Remission is achieved as a result of two components.

First, weight loss improves insulin sensitivity and reduces insulin resistance.

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Secondly, the restructuring of the small intestines actually increases hormone production that helps manage blood sugar levels. This impact is often seen immediately after surgery, versus the effects of eventual weight loss.

By 12 months post-surgery, that remission rate rose to 74 percent and persisted for the first five years after the procedure.

After five years, about 25 percent of the participants experienced a relapse of their type 2 diabetes diagnosis.

Remission doesn’t mean cured

“The definition for remission in this study is basically ‘pre-diabetes,’” explained Jennifer Okemah, RD, CDE, a registered dietitian from Kirkland, Washington.

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The study classified patients as “in remission” if they had an HbA1c under 6.5 percent and were taking no diabetes-related medications.

HbA1c (or A1c) is a measurement of your average blood sugar levels during the course of the prior three months.

The 6.5 percent translates to a blood sugar of 140 mg/dL, which is above the goal range for a healthy non-diabetic of 70 to 130 mg/dL.

For patients in the study who continued to take the diabetes drug metformin, remission is defined as an HbA1c of less than 6 percent. In other words, even though they were still taking medication to lower blood sugar levels, the study classified their diabetes as “in remission” if their HbA1c was low enough.

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“This surgery is not a cure and it’s important that patients understand that,” said Okemah, who has supported many of her patients with type 2 diabetes through weight-loss surgery.

“We have to differentiate between ‘remission’ and a ‘cure,'” Okemah told ishonest. “After this surgery, you will still need to follow the same diabetes nutrition guidelines. You have pre-diabetes and you’ll still need to manage it.”

While many believe that type 2 diabetes is simply the result of weight gain, inactivity, and a poor diet that leads to insulin resistance, it’s actually more complicated.

“Type 2 diabetes is a progressive disease,” said Okemah. “Even if you go into remission, we watch your blood sugars closely so we can get it to progress as slowly as possible.”

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Most patients with type 2 diabetes actually struggle to produce adequate amounts of insulin due to the loss of beta-cell function. Beta-cells are produced by the pancreas and play a critical role in the production of insulin, which carries the sugar in your bloodstream to every part of your body to use it for fuel.

Because type 2 diabetes is a progressive disease, Okemah says it’s imperative that patients understand the likelihood of their blood sugars eventually rising — even if they don’t gain back all of the weight — because of continued loss of beta-cell function.

The study was clear, however, that the patients with the least likelihood of achieving remission were those who required injections of insulin to manage their type 2 diabetes — as this is a clear indication of severe loss of beta- cell function.

Having realistic expectations

Okemah said gastric bypass surgery can be a last ditch effort by some people with type 2 diabetes.

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“They’ve tried every diet and they feel so defeated,” she said. “They think this is the last thing that might help them, but you have to make sure they have realistic expectations about life after surgery.”

Okemah added that patients are too often misinformed or uneducated by their healthcare team about what the surgery will do for them.

“A patient often thinks if they just get this surgery, their life is going to change. They won’t have diabetes anymore. They won’t be overweight anymore. But you’re still the same person, you’re still in the same life,” she said.

Most challenging for many patients undergoing the surgery are the lifestyle and emotional behaviors they had around food prior to surgery.

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“All of the habits that it took to get to that surgery, the surgical procedure does not fix those. And you can out-eat a surgery,” she explained.

While patients won’t have the physical capacity to over-indulge on something like a cheeseburger and a milkshake during the first two years after surgery, they can stretch their new stomach out over time, overeat regularly, and gain the weight back — along with their type 2 diabetes diagnosis.

“We also try not to put numbers in their heads about how much weight they’ll lose,” said Okemah.

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Most patients, she explained, likely won’t become the “thin” image they might have in their heads.

But Okemah says at that point, any weight loss is going to dramatically improve their health — especially when reducing the amount of fat in their midsection around their organs.

It’s normal for most patients to gain some weight back, but if they were to gain all of it back, it would be a sign that the patient was engaging again in harmful habits around food.

The complications of surgery

In obese patients without type 2 diabetes who undergo RYGB the percent of complications is 3.3 percent.

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The reason isn’t necessarily surprising. Higher blood sugar levels put the entire body in jeopardy. The body isn’t going to heal as well or simply function as well compared to an obese patient without diabetes.

The study did report a decrease in the incidence of long-term diabetes-related complications such as retinopathy in patients during the five-year post-op period.

The most startling complication of surgery, said Okemah, is one that is rarely talked about: its impact on your closest relationships.

“I see it all time. The patient’s spouse doesn’t like that they are losing weight, getting more attention, and changing. And they stop supporting them,” she said.

Sometimes, patients even regain weight purposefully to save their relationship.

“This is a huge surgery and every patient should approach it carefully,” Okemah emphasized.

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