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Surgery must be recognised as treatment option for Type 2 diabetes


A leading group of international diabetes organisations, including Diabetes UK, is calling for obesity surgery, also known as bariatric surgery, to be recognised as a standard treatment option for Type 2 diabetes.In a joint statement, published today (Tuesday 24 May) in the June 2016 edition of the journal Diabetes Care, the group state that obesity surgery, which was originally designed to induce weight loss, should be included among the current  treatment options for certain categories of people with Type 2 diabetes.The new guidelines state that surgery should be recommended to treat people with Type 2 diabetes who have the following Body Mass Index (BMI, which is a measure to see if you are a healthy weight for your height):•    40 and over (or 37.5 and over for Asian people) regardless of their blood glucose control•    35 and over (or 32.5 and over for Asian people) in people whose blood glucose levels are inadequately controlled by lifestyle changes and blood glucose lowering medication.The guidelines also state that surgery should be considered for people with a BMI of:•    30 and over (or 27.5 and over for Asian people) in people whose blood glucose levels are inadequately controlled by lifestyle changes and blood glucose lowering medication.(It is recommended that the BMI thresholds in Asian people with Type 2 diabetes should be lowered by an additional 2.5 because they develop Type 2 diabetes at a lower BMI compared to other populations.)

Substantial benefits

The guidelines are based on a wide body of evidence, including 11 randomised trials, showing that in most cases surgery can lead to reductions in blood glucose levels below the Type 2 diabetes diagnosis threshold or a substantial improvement in blood glucose levels leading to a reduction in medication. Economic studies also show that the treatment can be cost effective.The new guidelines emerged from the Second Diabetes Surgery Summit (DSS-II), an international consensus conference held September 28–30, 2015, in London, and jointly organised with Diabetes UK, the American Diabetes Association, International Diabetes Federation, Chinese Diabetes Society, and Diabetes India. The goal of the Summit was to develop global guidelines to inform clinicians and policy makers about benefits and limitations of Type 2 diabetes surgery.It is essential that people with diabetes have access to effective treatments and are supported to manage their condition well. This is because poorly controlled diabetes can lead to serious complications such as blindness, amputations and stroke. As well as the human cost, these complications are also extremely costly to the NHS. The NHS spends £10 billion every year managing diabetes, and 80 per cent of this cost is spent on complications.Diabetes UK is calling for the new guidelines to be fully incorporated into the existing guidelines for treating Type 2 diabetes so that everyone who fits the surgery criteria is assessed for treatment. While NICE updated its obesity surgery criteria for people with Type 2 diabetes in 2014, the specific recommendations in these guidelines do not appear in full in its Type 2 diabetes treatment guidelines, which was published last year.

Call for obesity surgery to be fully recognised as a Type 2 diabetes treatment option

Simon O’Neill, Director of Health Intelligence and Professional Liaison at Diabetes UK, said: “We strongly support the call for obesity surgery to be fully recognised as an active treatment option for Type 2 diabetes alongside established forms of Type 2 diabetes treatments, such as lifestyle changes, and blood glucose lowering medications. This is because there is a wide body of evidence that shows surgery is an effective treatment option for Type 2 diabetes and can be cost effective for the NHS.“However, many people who stand to benefit from this potentially lifesaving treatment are missing out due to needless barriers to obesity surgery services. Even people who meet the criteria for the surgery are being made to wait too long, even though we know that people with Type 2 diabetes benefit most from the surgery if it is carried out closer to the time they were diagnosed.“This is why the National Institute for Health and Care Excellence (NICE) must make it explicit in its Type 2 diabetes guidelines that those with Type 2 diabetes who meet the recommended criteria for obesity surgery should be referred for early assessment for surgery and supported to make an informed choice. These recommendations are currently stated in the NICE obesity guidelines, but are not fully incorporated in current NICE Type 2 diabetes guidelines.

Greater access to obesity surgery services needed

“It is also essential that healthcare professionals are aware of the potential benefits of surgery for their patients with Type 2 diabetes and commissioners ensure they have measures in place to support greater access to obesity surgery services.“Type 2 diabetes is a serious health condition that can lead to debilitating and life threatening complications so it is essential that all effective treatment options for people with Type 2 diabetes are made available.”“The UK is in the midst of an epidemic of diabetes, like many other countries around the world, and prevention of Type 2 diabetes remains crucial”; said Professor Francesco Rubino, Chair of Metabolic and Bariatric Surgery at King’s College London, Consultant surgeon at King’s College Hospital and first author on the guidelines report. “Prevention, however, is obviously no longer an option for the many patients diagnosed with Type 2 diabetes. These patients should have access to all effective treatment options; for some, surgery may be the best choice” – he added.Obesity surgery involves the removal of part of the stomach or reroutes the small intestine. Examples of these procedures include:•    Gastric bypass where the stomach is made smaller and food is allowed to bypass part of the small intestines. This makes you feel full quickly so you eat less but also in bypassing the small intestines you absorb less food.•    Gastric banding where an adjustable band is placed around the upper part of the stomach. This creates a pouch which can only hold small amount of food so you feel full quickly. •    Gastric sleeve, also known as sleeve gastrectomy, where a stapling device is used to remove a large portion of the stomach along the greater curvature. This creates a thin sleeve-like structure leaving less room in the stomach to hold food so you feel full quickly.   The surgery is similarly safe compared to commonly performed operations such as gallbladder surgery, but there is still a risk of complications and long term nutritional deficiencies, which require lifelong vitamin/nutritional supplementation and rigorous long-term follow up by specialist teams.

What about prevention?

Being overweight is a significant risk factor for Type 2 diabetes, but there are otherrisk factorsthat play an important part, such as age, family history, and ethnicity.

Nikki Joule, Policy Manager at Diabetes UK, said: “There is an urgent need to prevent further cases of Type 2 diabetes in addition to extending the range and effectiveness of treatments for people already living with diabetes. This is not an either / or – we need to treat those who have diabetes to avoid costly complications and do everything we can to prevent more people developing the condition. This is why Diabetes UK have jointly launched, Healthier You, the first ever national NHS Diabetes Prevention Programme, along with Public Health England and NHS England. The programme, which is designed based on the evidence of successful trials, will offer support to the 5 million people in England who are at high risk of developing Type 2 diabetes, to reduce their risk, through making changes to their diet and levels of physical activity.

“In addition we recognise that this programme on its own will not be sufficient to halt the rising tide of obesity and Type 2 diabetes. We are also calling for action to be taken across a range of areas to encourage people to lead healthier lives. This must include placing restrictions on marketing junk foods to children and government set targets for the food and drinks industry, to reduce the salt, fat and sugar content in their foods to make them healthier.”

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