Skip to main content

Advertisement

Log in

Obesity and Diabetes: The Impact of Bariatric Surgery on Type-2 Diabetes

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Weight gain and obesity are driving the global epidemic of type-2 diabetes through metabolic and inflammatory pathways that cause insulin resistance and impair pancreatic β-cell function, the two important factors that are directly responsible for the development of this disease in susceptible populations. Lifestyle methods and modest weight loss are powerful at preventing and managing type-2 diabetes, but sustaining substantial weight loss is problematic. Bariatric surgery provides exceptional sustained weight loss and remission of type-2 diabetes in 50–85% of subjects, especially if treated early before irreparable β-cell damage has occurred. In addition, there is substantial evidence that bariatric surgery provides additional comorbidity and quality-of-life improvements and reduces mortality in patients with type-2 diabetes. There is an association between the extent of weight loss and remission of type-2 diabetes. Diversionary bariatric procedures such as gastric bypass and biliopancreatic diversion induce a rapid non-weight-loss-associated improvement in glycemic control. Several mechanisms have been proposed for this exciting and novel effect that may provide key insights into the pathogenesis of type-2 diabetes. A range of novel surgical, endoluminal procedures/devices, and pharmacologic therapies are likely to evolve when we better understand how bariatric surgery enables long-term changes in energy balance and non-weight-related metabolic improvements. Bariatric surgery should be considered for adults with BMI ≥ 35 kg/m2 and type-2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. Although all bariatric procedures produce exceptional results in the management of type-2 diabetes, choice of procedure requires a careful risk–benefit analysis for the individual patient.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Zimmet P, Alberti KG, Shaw J (2001) Global and societal implications of the diabetes epidemic. Nature 414:782–787

    Article  PubMed  CAS  Google Scholar 

  2. National Institutes of Health (1980) Successful diet and exercise therapy is conducted in Vermont for “diabesity”. JAMA 243:519–520

    Article  Google Scholar 

  3. Astrup A, Finer N (2000) Redefining type 2 diabetes: ‘diabesity’ or ‘obesity dependent diabetes mellitus’? Obes Rev 1:57–59

    Article  PubMed  CAS  Google Scholar 

  4. Colditz GA, Willett WC, Rotnitzky A et al (1995) Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 122:481–486

    PubMed  CAS  Google Scholar 

  5. Chan JM, Rimm EB, Colditz GA et al (1994) Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 17:961–969

    Article  PubMed  CAS  Google Scholar 

  6. Leibson CL, Williamson DF, Melton LJ III et al (2001) Temporal trends in BMI among adults with diabetes. Diabetes Care 24:1584–1589

    Article  PubMed  CAS  Google Scholar 

  7. Gregg EW, Cheng YJ, Narayan KM et al (2007) The relative contributions of different levels of overweight and obesity to the increased prevalence of diabetes in the United States: 1976–2004. Prev Med 45:348–352

    Article  PubMed  Google Scholar 

  8. American Diabetes Association (2008) Economic costs of diabetes in the U.S. in 2007 (2008) Diabetes Care 31:596-615

    Google Scholar 

  9. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (2004) National Diabetes Statistics: Complications of diabetes in the United States. Available at http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#complications. Accessed 26 April 2009

  10. Lazar MA (2005) How obesity causes diabetes: not a tall tale. Science 307:373–375

    Article  PubMed  CAS  Google Scholar 

  11. Kershaw EE, Flier JS (2004) Adipose tissue as an endocrine organ. J Clin Endocrinol Metab 89:2548–2556

    Article  PubMed  CAS  Google Scholar 

  12. Boden G (2001) Free fatty acids—the link between obesity and insulin resistance. Endocr Pract 7:44–51

    PubMed  CAS  Google Scholar 

  13. Ruan H, Lodish HF (2004) Regulation of insulin sensitivity by adipose tissue-derived hormones and inflammatory cytokines. Curr Opin Lipidol 15:297–302

    Article  PubMed  CAS  Google Scholar 

  14. Boden G, Shulman GI (2002) Free fatty acids in obesity and type 2 diabetes: defining their role in the development of insulin resistance and beta-cell dysfunction. Eur J Clin Invest 32(Suppl 3):14–23

    Article  PubMed  CAS  Google Scholar 

  15. Lu JY, Huang KC, Chang LC et al (2008) Adiponectin: a biomarker of obesity-induced insulin resistance in adipose tissue and beyond. J Biomed Sci 15:565–576

    Article  PubMed  CAS  Google Scholar 

  16. Rhodes CJ (2005) Type 2 diabetes—a matter of beta-cell life and death? Science 307:380–384

    Article  PubMed  CAS  Google Scholar 

  17. Weir GC, Bonner-Weir S (2004) Five stages of evolving beta-cell dysfunction during progression to diabetes. Diabetes 53(Suppl 3):S16–S21

    Article  PubMed  CAS  Google Scholar 

  18. Wajchenberg BL (2007) Beta-cell failure in diabetes and preservation by clinical treatment. Endocr Rev 28:187–218

    Article  PubMed  CAS  Google Scholar 

  19. Guillausseau PJ, Meas T, Virally M et al (2008) Abnormalities in insulin secretion in type 2 diabetes mellitus. Diabetes Metab 34(Suppl 2):S43–S48

    Article  PubMed  CAS  Google Scholar 

  20. U.K. Prospective Diabetes Study Group (1995) U.K. prospective diabetes study 16. Overview of 6 years’ therapy of type II diabetes: a progressive disease. U.K. Prospective Diabetes Study Group. Diabetes 44:1249–1258

    Article  Google Scholar 

  21. U.K. Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 352:837–853

    Article  Google Scholar 

  22. U.K. Prospective Diabetes Study Group (1999) Quality of life in type 2 diabetic patients is affected by complications but not by intensive policies to improve blood glucose or blood pressure control (UKPDS 37). U.K. Prospective Diabetes Study Group. Diabetes Care 22:1125–1136

    Article  Google Scholar 

  23. U.K. Prospective Diabetes Study Group (1998) Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: (UKPDS 38). U.K. Prospective Diabetes Study Group [see comments]. BMJ 317:703–713 Erratum. BMJ 1999 Jan 2; 318(7175):29

    Google Scholar 

  24. Williamson DF, Thompson TJ, Thun M et al (2000) Intentional weight loss and mortality among overweight individuals with diabetes. Diabetes Care 23:1499–1504

    Article  PubMed  CAS  Google Scholar 

  25. Knowler WC, Barrett-Connor E, Fowler SE et al (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393–403

    Article  PubMed  CAS  Google Scholar 

  26. Tuomilehto J, Lindstrom J, Eriksson JG et al (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343–1350

    Article  PubMed  CAS  Google Scholar 

  27. Pi-Sunyer X, Blackburn G, Brancati FL et al (2007) Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care 30:1374–1383

    Article  PubMed  Google Scholar 

  28. Eriksson KF, Lindgarde F (1991) Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmo feasibility study. Diabetologia 34:891–898

    Article  PubMed  CAS  Google Scholar 

  29. MacDonald KG Jr, Long SD, Swanson MS et al (1997) The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg 1:213–220

    Article  PubMed  Google Scholar 

  30. Norris SL, Zhang X, Avenell A et al (2004) Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 117:762–774

    Article  PubMed  Google Scholar 

  31. Khan MA, St. Peter JV, Breen GA et al (2000) Diabetes disease stage predicts weight loss outcomes with long-term appetite suppressants. Obes Res 8:43–48

    Article  PubMed  CAS  Google Scholar 

  32. Zimmet P, Shaw J, Alberti KG (2003) Preventing type 2 diabetes and the dysmetabolic syndrome in the real world: a realistic view. Diabet Med 20:693–702

    Article  PubMed  CAS  Google Scholar 

  33. Wing RR, Marcus MD, Epstein LH et al (1987) Type II diabetic subjects lose less weight than their overweight nondiabetic spouses. Diabetes Care 10:563–566

    Article  PubMed  CAS  Google Scholar 

  34. Pories WJ, Swanson MS, MacDonald KG et al (1995) Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 222:339–350; discussion 350–352

    Article  PubMed  CAS  Google Scholar 

  35. Pories WJ, MacDonald KG Jr, Morgan EJ et al (1992) Surgical treatment of obesity and its effect on diabetes: 10-y follow-up. Am J Clin Nutr 55:582S–585S

    PubMed  CAS  Google Scholar 

  36. Pories WJ, Albrecht RJ (2001) Etiology of type II diabetes mellitus: role of the foregut. World J Surg 25:527–531

    Article  PubMed  CAS  Google Scholar 

  37. Buchwald H, Avidor Y, Braunwald E et al (2004) Bariatric surgery: a systematic review and meta-analysis. JAMA 292:1724–1737

    Article  PubMed  CAS  Google Scholar 

  38. Vetter ML, Cardillo S, Rickels MR et al (2009) Narrative review: effect of bariatric surgery on type 2 diabetes mellitus. Ann Intern Med 150:94–103

    PubMed  Google Scholar 

  39. Higgins JPT, Green S (eds) (2008) Cochrane handbook for systematic reviews of interventions ver. 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. Available at www.cochrane-handbook.org. Accessed 4 February 2009

  40. Pontiroli AE, Pizzocri P, Librenti MC et al (2002) Laparoscopic adjustable gastric banding for the treatment of morbid (grade 3) obesity and its metabolic complications: a three-year study. J Clin Endocrinol Metab 87:3555–3561

    Article  PubMed  Google Scholar 

  41. Sjostrom L, Lindroos AK, Peltonen M et al (2004) Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 351:2683–2693

    Article  PubMed  Google Scholar 

  42. Dixon JB, O’Brien PE, Playfair J et al (2008) Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 299:316–323

    Article  PubMed  CAS  Google Scholar 

  43. Sjostrom CD, Lissner L, Wedel H et al (1999) Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res 7:477–484

    PubMed  CAS  Google Scholar 

  44. Torgerson JS (2003) Swedish obese subjects—where are we now? Int J Obes 27:19

    Article  Google Scholar 

  45. Sjostrom L, Narbro K, Sjostrom CD et al (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 357:741–752

    Article  PubMed  Google Scholar 

  46. Keating CL, Dixon JB, Moodie ML et al (2009) Cost-efficacy of surgically induced weight loss for the management of type 2 diabetes: randomised controlled trial. Diabetes Care 32:580–584

    Article  PubMed  Google Scholar 

  47. Keating CL, Dixon JB, Moodie ML et al (2009) Cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes: modelled lifetime analysis. Diabetes Care 32:567–574

    Article  PubMed  Google Scholar 

  48. Dixon JB, O’Brien P (2002) Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care 25:358–363

    Article  PubMed  Google Scholar 

  49. Dixon JB, Dixon AF, O’Brien PE (2003) Improvements in insulin sensitivity and beta-cell function (HOMA) with weight loss in the severely obese. Diabet Med 20:127–134

    Article  PubMed  CAS  Google Scholar 

  50. Schauer PR, Burguera B, Ikramuddin S et al (2003) Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg 238:467–485

    PubMed  Google Scholar 

  51. Clauson P, Linnarsson R, Gottsater A et al (1994) Relationships between diabetes duration, metabolic control and beta-cell function in a representative population of type 2 diabetic patients in Sweden. Diabet Med 11:794–801

    Article  PubMed  CAS  Google Scholar 

  52. Polonsky KS, Gumbiner B, Ostrega D et al (1994) Alterations in immunoreactive proinsulin and insulin clearance induced by weight loss in NIDDM. Diabetes 43:871–877

    Article  PubMed  CAS  Google Scholar 

  53. Gumbiner B, Van Cauter E, Beltz WF et al (1996) Abnormalities of insulin pulsatility and glucose oscillations during meals in obese noninsulin-dependent diabetic patients: effects of weight reduction. J Clin Endocrinol Metab 81:2061–2068

    Article  PubMed  CAS  Google Scholar 

  54. Sugerman HJ, Wolfe LG, Sica DA (2003) Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss. Ann Surg 237:751–756; discussion 757–758

    Article  PubMed  Google Scholar 

  55. Taylor R (2008) Pathogenesis of type 2 diabetes: tracing the reverse route from cure to cause. Diabetologia 51:1781–1789

    Article  PubMed  CAS  Google Scholar 

  56. Rubino F (2008) Is type 2 diabetes an operable intestinal disease? A provocative yet reasonable hypothesis. Diabetes Care 31(Suppl 2):S290–S296

    Article  PubMed  Google Scholar 

  57. Cohen RV, Schiavon CA, Pinheiro JS et al (2007) Duodenal-jejunal bypass for the treatment of type 2 diabetes in patients with body mass index of 22–34 kg/m2: a report of 2 cases. Surg Obes Relat Dis 3:195–197

    Article  PubMed  Google Scholar 

  58. le Roux CW, Aylwin SJ, Batterham RL et al (2006) Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg 243:108–114

    Article  PubMed  Google Scholar 

  59. Holdstock C, Zethelius B, Sundbom M et al (2008) Postprandial changes in gut regulatory peptides in gastric bypass patients. Int J Obes (Lond) 32:1640–1646

    Article  CAS  Google Scholar 

  60. Laferrere B, Teixeira J, McGinty J et al (2008) Effect of weight loss by gastric bypass surgery versus hypocaloric diet on glucose and incretin levels in patients with type 2 diabetes. J Clin Endocrinol Metab 93:2479–2485

    Article  PubMed  CAS  Google Scholar 

  61. Wang TT, Hu SY, Gao HD et al (2008) Ileal transposition controls diabetes as well as modified duodenal jejunal bypass with better lipid lowering in a nonobese rat model of type II diabetes by increasing GLP-1. Ann Surg 247:968–975

    Article  PubMed  Google Scholar 

  62. Strader AD, Vahl TP, Jandacek RJ et al (2005) Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats. Am J Physiol Endocrinol Metab 288:E447–E453

    Article  PubMed  CAS  Google Scholar 

  63. Rubino F, Forgione A, Cummings DE et al (2006) The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg 244:741–749

    Article  PubMed  Google Scholar 

  64. Gersin KS, Keller JE, Stefanidis D et al (2007) Duodenal-jejunal bypass sleeve: a totally endoscopic device for the treatment of morbid obesity. Surg Innov 14:275–278

    Article  PubMed  Google Scholar 

  65. Rodriguez-Grunert L, Galvao Neto MP, Alamo M et al (2008) First human experience with endoscopically delivered and retrieved duodenal-jejunal bypass sleeve. Surg Obes Relat Dis 4:55–59

    Article  PubMed  Google Scholar 

  66. Wickremesekera K, Miller G, Naotunne TD et al (2005) Loss of insulin resistance after Roux-en-Y gastric bypass surgery: a time course study. Obes Surg 15:474–481

    Article  PubMed  Google Scholar 

  67. Meirelles K, Ahmed T, Culnan DM et al (2009) Mechanisms of glucose homeostasis after Roux-en-Y gastric bypass surgery in the obese, insulin-resistant Zucker rat. Ann Surg 249:277–285

    Article  PubMed  Google Scholar 

  68. Service GJ, Thompson GB, Service FJ et al (2005) Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 353:249–254

    Article  PubMed  CAS  Google Scholar 

  69. Z’Graggen K, Guweidhi A, Steffen R et al (2008) Severe recurrent hypoglycemia after gastric bypass surgery. Obes Surg 18:981–988

    Article  PubMed  Google Scholar 

  70. Bantle JP, Ikramuddin S, Kellogg TA et al (2007) Hyperinsulinemic hypoglycemia developing late after gastric bypass. Obes Surg 17:592–594

    Article  PubMed  Google Scholar 

  71. Clancy TE, Moore FD Jr, Zinner MJ (2006) Post-gastric bypass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia. J Gastrointest Surg 10:1116–1119

    Article  PubMed  Google Scholar 

  72. Cummings DE (2005) Gastric bypass and nesidioblastosis—too much of a good thing for islets? N Engl J Med 353:300–302

    Article  PubMed  CAS  Google Scholar 

  73. Chapman A, Kiroff G, Game P et al (2004) Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic review. Surgery 135:326–351

    Article  PubMed  Google Scholar 

  74. Gasteyger C, Suter M, Gaillard RC et al (2008) Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation. Am J Clin Nutr 87:1128–1133

    PubMed  CAS  Google Scholar 

  75. American Diabetes Association (2009) Standards of medical care in diabetes—2009. Diabetes Care 32(Suppl 1):S13–S61

    Google Scholar 

  76. Dixon JB, Pories WJ, O’Brien PE et al (2005) Surgery as an effective early intervention for diabesity: why the reluctance? Diabetes Care 28:472–474

    Article  PubMed  Google Scholar 

  77. Adams TD, Gress RE, Smith SC et al (2007) Long-term mortality after gastric bypass surgery. N Engl J Med 357:753–761

    Article  PubMed  CAS  Google Scholar 

  78. Sturm R (2007) Increases in morbid obesity in the USA: 2000–2005. Public health 121:492–496

    Article  PubMed  CAS  Google Scholar 

  79. Dixon JB (2008) Referral for a bariatric surgical consultation: it is time to set a standard of care. Obes Surg

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to John B. Dixon.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dixon, J.B. Obesity and Diabetes: The Impact of Bariatric Surgery on Type-2 Diabetes. World J Surg 33, 2014–2021 (2009). https://doi.org/10.1007/s00268-009-0062-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-009-0062-y

Keywords

Navigation