Managing Expectations for Diabetes Remission

| July 1, 2022

by Lori Wenz, RN, MSN, AGNP-C, BC-ADM 

Ms. Wenz is with Intermountain Health in Modesto, California. 

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(7):8.

Abstract

Bariatric surgery is a recommended treatment for patients with obesity-associated diabetes. Preoperative patient education can help patients to develop realistic expectations for how surgery can improve their diabetes. While many patients will experience diabetes remission for years, others will experience varying degrees of improvement in their disease. Unrealistic expectations can result in patients feeling a sense of defeat or personal failure if diabetes returns after surgery, or if they are unable to stop or need to resume diabetes medications. Discussing diabetes as a chronic disease, along with the rates and predictors of disease remission after bariatric surgery, will help patients to establish realistic expectations for treating diabetes. In this way, patients will understand that diabetes after bariatric surgery is not a personal failure, but instead a risk of having a chronic disease. 

Keywords: Bariatric surgery, diabetes, diabetes remission, diabetes resolution, diabetes treatment, obesity, obesity-associated diabetes

Multiple guidelines recommend bariatric surgery as a treatment for diabetes.1–3 While many patients do experience diabetes remission and will be able stop all medications after surgery, some will continue to have diabetes to some degree after surgery, and others will experience a relapse of their disease over time.4–7 When patients expect diabetes remission and this is not the outcome, they often experience feelings of guilt, shame, and failure. Providing preoperative patient education on diabetes as a chronic disease, along with the rates and predictors of diabetes remission after bariatric surgery, allows patients to develop realistic expectations for treating diabetes. Informing patients in this way helps them understand diabetes might continue or return after surgery, and if this happens, it is not due to personal failure.

Predictors of diabetes remission. Current evidence has identified several factors associated with obesity-associated diabetes remission after bariatric surgery, including age, years with diabetes, number of medications used to treat diabetes, body mass index (BMI) before surgery, and type of surgery.4–7 A few tools have been developed using these criteria to assist in calculating the probability for diabetes remission within two years and five years after bariatric surgery.5,8 Discussing this information with patients before surgery allows for shared decision-making and establishing realistic expectations for treating diabetes. Below, the predictors for diabetes remission following bariatric surgery are described. 

  1. Age. The younger a patient is at the time of surgery, the increased likelihood there is of diabetes remission. Patients under 40 years of age are most likely to have their diabetes resolved after surgery, and those over 60 years of age are less likely to resolve their diabetes long-term.4–7 
  2. Diabetes duration. Patients who have longstanding diabetes are less likely to experience diabetes remission after bariatric surgery.5–7 Over time, patients with diabetes might experience decreased insulin production, in turn making remission less likely and diabetes more difficult to control.5,6 
  3. Weight. Patients with higher weights before surgery are more likely to have diabetes remission than those with lower weight before surgery.5–7 A BMI of 44kg/m2 or higher is associated with greater likelihood of disease remission.5–7 
  4. Number of medications. Fewer oral medications required to control diabetes before surgery is associated with greater diabetes remission and better glucose control after bariatric surgery.5–8 Insulin therapy before surgery is associated with decreased probability of diabetes remission.5–8 
  5. Surgery type. Evidence supports either the Roux-en-Y gastric bypass (RYGB) or loop duodenal switch (DS) as providing the highest incidence of diabetes resolution, although evidence is more limited for loop DS.6
  6. Predictive tools. A few tools are available to quantify the probability of diabetes remission after bariatric surgery. The DiaRem calculation tool was developed to predict the diabetes remission within two years or less after RYGB.8 The Advanced-DiaRem tool was later developed to predict diabetes remission at five years after RYGB, gastric banding, or sleeve gastrectomy.8 

Using the criteria discussed above, a 38-year-old patient with a history of obesity-associated diabetes for three years, is on three different oral medications, with an A1C of 6.8 percent and a BMI of 49m/kg2 has a 100 percent probability of diabetes remission at five years after RYGB. In contrast, a 62-year-old patient who has had diabetes for 20 years and is on three oral diabetes medications and high doses of insulin has an 18.5 percent probability of diabetes remission at five years after RYGB.

Bariatric surgery is an excellent option for the treatment of diabetes, but the expectations for diabetes remission for these two patient examples are very different. While both will experience weight reduction and improved glucose control, long-term diabetes remission is unlikely for the older patient with longstanding disease. If this patient’s goal is lifelong diabetes remission without the use of any medication, they are likely to be disappointed if their disease continues or returns after surgery. It is important to counsel patients that diabetes is a chronic disease and the risk that the disease will return after surgery increases over time.4–7 Educating patients on the rates and predictors of diabetes remission after bariatric surgery helps patients to understand there are many factors associated with the disease that cannot be controlled, and a return of the disease is not a personal failure. 

References

  1. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures–2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Rel Dis. 2020;16(2):175–247. 
  2. American Diabetes Association. Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers. Clin Diabetes. 2022;40(1):10–38. 
  3. Bays HE, McCarthy W, Burridge K, et al. Obesity Algorithm eBook, presented by the Obesity Medicine Association. 2021. https://obesitymedicine.org/obesity-algorithm/. Accessed 11 Feb 2022.
  4. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial–a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273(3):219–234. 
  5. Lee WJ, Hur KY, Lakadawala M, et al. Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score. Surg Obes Relat Dis. 2013;9(3):379–384.
  6. Chumakova-Orin M, Vanetta C, Moris DP, Guerron AD. Diabetes remission after bariatric surgery. World J Diabetes. 2021;12(7):1093–1101. 
  7. Fultang J, Chinaka U, Rankin J, et al. Preoperative bariatric surgery predictors of Type 2 diabetes remission. J Obes Metab Synd. 2021;30(2):104–114. 
  8. Dicker D, Golan R, Aron-Wisnewsky J, et al. Prediction of long-term diabetes remission after RYGB, sleeve gastrectomy, and adjustable gastric banding using DiaRem and Advanced-DiaRem scores. Obes Surg. 2019;29(3):796–804. 

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