Bariatric Surgery in Patients With Morbid Obesity and Type 2 Diabetes

• GLP, glucagon-like peptide

There is an epidemic of obesity throughout the developed and much of the developing world (1–3). Obesity, typically measured as BMI ≥30 kg/m², has three subclasses: obesity 1 (30–34.9 kg/m²); obesity 2 (35–39.9 kg/m²); and extreme obesity (>40 kg/m²). Extreme or morbid obesity is rapidly increasing in the U.S. and may have the potential of decreasing life expectancy. From 1986 to 2000, the prevalence of BMI >30 kg/m² doubled, whereas that of BMI ≥40 kg/m² quadrupled, and even extreme obesity of BMI ≥50 kg/m² increased fivefold (2). Of particular concern is the alarming increasing prevalence of obesity among children (1), suggesting that the epidemic will worsen before it improves. Epidemiologic studies have demonstrated that increasing BMI is a causative factor in many life-threatening comorbidities, including type 2 diabetes, cardiovascular disease, and cancer. BMI has been established as an independent risk factor for premature mortality (4). Obesity is a major independent risk factor for the development of type 2 diabetes and is associated with the rapid increase in the prevalence of type 2 diabetes (3). In the U.S., the majority diagnosed with type 2 diabetes are overweight, with 50% obese (i.e., BMI >30 kg/m²) and 9% morbidly obese (BMI >40 kg/m²) (5). This twin epidemic of obesity and diabetes carries severe consequence for premature mortality (6).

Lifestyle intervention programs with diet therapy, behavior modification, exercise programs, and pharmacotherapy are widely used in various combinations. Unfortunately, with extremely rare exceptions (7), clinically significant weight loss is generally very modest and transient, particularly in patients with severe obesity. In a recently published study (8), 80 adults with mild to moderate obesity (BMI 30–35 kg/m²) were randomized to nonsurgical intervention (very-low-calorie diet, orlistat, and lifestyle change) or to surgical intervention …