Schauer, P.R., Rubino, F., The IDF Position Statement on Bariatric Surgery for Type 2 Diabetes: Implications for Patients, Physicians and Surgeons, Surgery for Obesity and Related Diseases, (2011), doi: 10.1016/j.soard.2011.05.015.
The International Diabetes Federation (IDF) Position Statement on bariatric surgery co-published in this month’’s issue of Surgery for Obesity and Related Diseases (SOARD) and other obesity, endocrine and diabetes journals is a major step forward in global recognition of metabolic surgery as specific treatment of diabetes, not just obesity. Surgeons, internists, diabetologists, primary care physicians and other health care providers who manage patients with diabetes should carefully read this document as it provides very important, practical, evidenced based recommendations on how to best utilize surgery for treating type 2 diabetes mellitus (T2DM). It is the most comprehensive position statement or guideline yet published.
The Key points of the Position Statement
The IDF expert panel reviewed data related to both conventional, standard bariatric operations as well as novel interventional procedures. For severely obese (BMI >35 kg/m2) diabetic patients the following standard procedures were considered in the clinical recommendations of the IDF statement: gastric banding, sleeve gastrectomy, gastric bypass, biliopancreatic diversion and duodenal switch. There was general agreement that while novel surgical procedures (i.e. Duodenal Jejunal Bypass and Ileal Interposition) and GI device interventions (i.e. endoluminal procedures and electrophysiologic interventions) represent interesting and promising approaches for the treatment of diabetes and obesity, their clinical use should still be considered investigational. Since very few comparative studies have been conducted comparing surgical procedures head to head, the expert panel did not make specific recommendations on specific procedures and called for RCT studies as an important research priority.
In agreement with the DSS and ADA position statements/guidelines the IDF document states that ““Bariatric surgery is an appropriate treatment for people with type 2 diabetes and severe obesity (BMI equal to or greater than 35 kg/m2).”” The IDF statement goes one step further by pronouncing that surgery ““should be prioritized for severely obese patients (BMI > 35 kg/m2) with T2DM”” as opposed to suggesting that it is merely ““an option””. This prioritization for surgery ( i.e. surgery should be an accepted option ) stems from the fact that severely obese patients are often refractory to conventional therapy with insulin and oral agents due to severe insulin resistance. The IDF statement agrees with the DSS recommendation that ““ under some circumstances people with a BMI 30-35 kg/m2 should be considered for surgery””. Such circumstances include HbA1c greater than 7.5% despite fully optimized conventional therapy, especially if weight is increasing, or in the presence of other weight responsive co-morbidities not achieving targets on conventional therapies (i.e. blood pressure, dyslipidemia and obstructive sleep apnea). .
For Asian and some other ethnicities of increased risk, BMI action points for surgery may be lower (eg. 27. 5kg/m2 to 32.5 kg/m2 ) according to the IDF statement.. The IDF statement encourages a wiser use of BMI in the selection of surgical candidates, recognizing the limitations of this parameter and its variability with age, gender and ethnicity. The IDF statement also recommends that surgery should be integrated as a treatment option in the algorithm of diabetes management, along with lifestyle modifications and pharmacologic therapy . This is a real and practical step forward since none of the professional diabetes organizations such as ADA, AACE, or EASD has yet incorporated surgery into their standard treatment algorithms.
The IDF position statement also recommends that diabetes-specific parameters be systematically measured in order to obtain a proper preoperative characterization of the disease as well as reliable and reproducible measures of postoperative outcomes. In addition to anthropometric measures, diabetes measures should include HbA1c, fasting glucose and insulin, retinopathy status, test for microalbuminuria, lipid profile, documentation of medications, as well as fasting C-peptide and auto-antibody (e.g. anti-GAD) where available.
Why is the IDF statement a ““game changer”” in bariatric/metabolic surgery?
The formal recognition of surgery as a valuable option for diabetes by an authoritative organization such as the IDF will hopefully influence national diabetes societies and thousands of physicians worldwide.
In fact, the IDF Position Statement places the role of bariatric interventions, for the first time, into a public health, clinical and socio-economic perspective. This will predictably increase awareness of diabetes surgery among the medical community and the public at large.
The IDF recommendations have both conceptual and practical ramifications. First, they emphasize that a surgical approach should be considered earlier in the treatment of type 2 diabetes and no longer be seen as a last resort. Furthermore, the distinction between conditions of eligibility for surgery vs. conditions when surgery is recommended allows a rational approach to prioritize access to surgical treatment until further data allow the identification of more reliable predictors of risk/benefit profile, especially in patients with lower BMI levels.
An important merit of the IDF position statement is the introduction of clinical considerations for patient selection recognizing the relevance of disease stage and cardiovascular (CV) risk rather than BMI alone. In particular, the IDF document suggests that bariatric surgery may be a reasonable option for patients who are not achieving recommended treatment targets with medical therapy, especially where there are other obesity related co-morbidities that increase CV risk. This is an important element of novelty that introduce more clinically meaningful criteria for patients selection, whereas so far indication for bariatric surgery has been based on rigid and absolute BMI cutoffs, an approach that has almost no equivalent in other field of surgery.
For the first time, the IDF statement recognizes that BMI action points for surgery should be lower for certain ethnicities. Previous guidelines based on strict BMI cutoffs did not recognize the significant differences in BMI-associated health risk among ethnic groups, creating a potential barrier for equitable access to surgery.
The recognition that the surgical approach to diabetes should be recommended and prioritized in certain circumstances (i.e. BMI >35kg/m2, uncontrolled hyperglycemia, weight gain and substantial CV risk) is a fundamental shift from previous guidelines that considered the above circumstances as a condition of simple eligibility for bariatric surgery. This is not a semantic difference and will hopefully increase access to surgery from the current <2% of eligible patients to a more ““physiologic”” figure, as appropriate for a treatment option that is both life-saving and cost-effective. With most insurance carriers and national health systems already covering bariatric surgery for patients with BMI greater than 35 kg/m2, the IDF Position Statement can have an immediate impact and ensure that more patients will be able to benefit from bariatric/metabolic surgery.
Barriers to surgical access are not limited to lack of insurance coverage. Lack of awareness, the stigma and discrimination against obesity, misperceptions regarding the safety of bariatric surgery are still very pervasive in the medical community and among the public at large. Hopefully, the IDF statement will help develop the field in a more rational and less ““emotional”” way.
The recommendation that surgery should be considered early in the management of diabetes and, even more, the call for a formal inclusion of surgery in the algorithm of diabetes management have practical implications for endocrinologists, family physicians and health care providers involved in the management of diabetic patients.
As of today referral for bariatric surgery is rarely the result of counseling with primary care physicians or diabetes specialists; when this happens, it is usually in response to specific requests from patients who are often self-referred or self informed.
Physicians and endocrinologists, with individual exceptions, do not usually consider surgery as an option for a patient that is seeking medical attention for T2DM, regardless of their BMI level. Plainly, measuring BMI as a criterion to decide which treatment strategy to pursue is not a standard practice in most medical offices.
The IDF position statement implies that diabetes specialists and family physicians recognize surgery as one of the legitimate options in the armamentarium of therapies forT2DM. Patients from now on should be informed and appropriately counseled about surgical treatment of diabetes. The inclusion of interventional therapies in the algorithm of diabetes management will allow physicians to escalate treatment according to disease stage and severity.
Extract from Surgery for Obesity and Related Diseases, May 2011