Pre-Bariatric Surgery Info Critical for Long-Term Prediction of Diabetes Remission

So Jeshurun grew fat and kicked – You grew fat and gross and coarse – He forsook the God who made him and spurned the Rock of his support. Genesis 32:15 (The Israel Bible™)

Type-2 diabetics develop their chronic metabolic disease – in most cases – from being overweight and even morbidly obese, eating junk food and leading a sedentary life. Until recently it was thought to be irreversible but manageable by taking medications and/or injecting insulin, exercising and observing a restricted, healthful diet.

But the use of bariatric – weight-loss – surgery on obese patients with or without diabetes has put the disease in a new perspective. In some patients, gastric-bypass surgery that reduces the amount of food intake in the stomach can achieve remission of diabetes and even cure it.

The operation has also been linked to a lower incidence of myocardial infarction (29%), stroke (34%), cancer in women (42%) and overall mortality (30–40%). But many patients and their doctors regard bariatric surgery as a draconian last-resort step for obesity and diabetes management, in part due to surgical risks as well as uncertainty about long-term efficacy.

Surgeons and diabetologists have been unable to predict which diabetes patients would benefit from bariatric surgery – a major, costly and occasionally risky procedure – and whose diabetes would not go into remission.

The most common type of bariatric operation is the Roux-en-Y gastric bypass (RYGB), which involves creating a small pouch from the stomach and connecting it directly to the small intestine. After the surgery, swallowed food goes into this small stomach pouch and then directly into the small intestine, thereby bypassing most of the stomach and the first section of your small intestine.

Because of the costs, health risks and uncertain long-term results, it is critical to develop methods for predicting outcomes that are applicable for clinical practice. “This calls for institution of effective therapies to deal with the rising trend of complications arising out of this dual menace,” the authors wrote.

Although lifestyle changes form the cornerstone of therapy for both the ailments, sustained results from are far from satisfactory. Half of all obese diabetes patients who diet and take medications bounce back to their original weight and glucose levels within four years. Bariatric surgery, however, can make a lasting difference in about 80% of diabetic patients, but in the rest, it fails to make a lasting impact.  

Ben-Gurion University of the Negev researchers in Beersheba now believe they have changed all that. They developed a pre-operative examination of key health indicators that has proven itself to be an accurate predictor in the medium term and not only short term of achieving diabetes remission in patients who undergo the surgery.

Pre-surgical analysis of a patient’s age, body-mass index, diabetes indicators and treatment can predict the outcome of bariatric surgery, according to Dr. Rachel Golan a lecturer in the BGU Faculty of Health Sciences’ department of public health and Prof. Assaf Rudich of the faculty’s clinical biochemistry and pharmacology department. Their clinical scoring system is called Advanced-DiaRem (short for diabetes remission).

In a comprehensive study just published online in the academic journal for bariatric surgeons Obesity Surgery, using Advanced-DiaRem information was shown to improve doctors’ ability to predict diabetics’ reaction to weight-reducing surgery for up to five years. Ordinary DiaRem, a clinical scoring system designed to predict diabetes remission RYGB, is not accurate for all individuals across the entire spectrum of scores and for many years after the surgery.

The team developed Advanced-DiaRem by using data from a computerized database of 1,459 obese persons with type 2 diabetes who underwent bariatric surgery.

“Previously, the DiaRem model was limited to the prediction for just one year, after a single-type of procedure,” said Golan. “We showed that by using our improved predicting score, the Advanced-DiaRem, we were able to predict the long-term probability that the patient undergoing surgery would achieve a remission of their diabetes.”

The “breakthrough,” the authors said, is likely to play an increasingly prominent role in public health debates as obesity rates, considered the most prevalent preventable risk factor for morbidity and mortality in Western countries, continue to soar at epidemic levels.

“On the most local level, the ability to predict an individual’s reaction to surgery will give both doctors and patients the clarity they need to make informed medical decisions. And at the macro level, it will allow healthcare officials to address a major public health crisis that is one of the major contributors to the spiraling cost of health care, and direct specific resources to where they can be most effective in a personalized manner,” said Dr. Golan.

Golan and Rudich were assisted by Israel’s National Institute of Biotechnology in the Negev, Dr. Dror Dicker of the Israeli Society for Research and Treatment of Obesity, researchers from the Rabin Medical Center in Petah Tikva, Israel, Clalit Health Services and Sorbonne University in Paris.

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