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They aren’t obese // They don’t have high BMIs // They look healthy // But they don’t have freedom... // From insulin // From the possibility of dialysis // From the risk of organ failure.

Bypassing Diabetes

By Charles Slack // Photographs by Alessandra Petlin // Fall 2008
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gastric bypass surgery, diabetes

Gastric bypass surgery can be a lifesaver. For the morbidly obese who can’t keep weight off with diet or exercise, having the stomach surgically downsized typically results in a dramatic, permanent drop in pounds and a 50% reduction in mortality compared with people of similar girth who do not have the surgery. Laparoscopic techniques, meanwhile, have decreased discomfort and recovery times, helping to fuel a nearly 1,500% rise in the number of procedures, from fewer than 14,000 in 1998 to 200,000 in 2006.

Philip Schauer, a surgeon at the Cleveland Clinic, performs hundreds of these procedures, also known as bariatric surgery, each year. But the case of one 37-year-old patient in September 2007 was different from most. Though the woman was about 30 pounds overweight, with a body mass index (BMI) of 33, she wasn’t clinically obese and would not normally have been a candidate for weight loss surgery. But for nearly a decade, she’d had another problem—type 2 diabetes, an increasingly prevalent condition in which the body responds improperly to insulin, a hormone that regulates blood sugar. She hadn’t been able to control the disease with medication, so now she was going under the knife. The results were striking. Within days, the woman’s blood sugar levels had stabilized, and after a few weeks, she no longer needed medication for her diabetes.

For nearly two decades, physicians have known that gastric bypass surgery has a profound effect on type 2 diabetes. As in this case, symptoms virtually disappear, and they don’t usually return. It’s apparently not just the weight loss, either. Schauer and others think there is something more complex going on, some kind of surgically induced metabolic change that spurs the production of insulin and makes “cure” seem a reasonable assessment of what proponents have begun to refer to as diabetes surgery.

But the success of this procedure raises important questions, and none may be more crucial than who should undergo it. While surgeons in the United States and Europe continue to debate just where on the BMI scale to draw the line, Brazilian doctors have taken a stunning step. In a recent study, surgeons in São Paulo performed gastric bypass procedures on 39 patients (16 women and 23 men) who had an average BMI of 30.1—someone who is 5 ft. 6 in. and weighs about 187 pounds. What’s more, the thinnest patient had a BMI of 23.4, which translates into a six-footer, for example, who weighs less than 175 pounds. In their report, the Brazilian doctors noted that all of these patients had had chronic diabetes for at least three years. And in almost 90% of the cases, the surgery stabilized blood sugar levels, essentially stopping diabetes in its tracks.

The Brazilian study, among other developments, prompted 150 surgeons, endocrinologists, weight loss experts and other medical professionals to convene in Rome last year for the first Diabetes Surgery Summit. In a follow-up report published in 2008, Schauer and three other conference leaders were optimistic about what surgery could accomplish, writing that “whereas diabetes is traditionally viewed as a chronic, relentless disease in which delay of end-organ complications is the major treatment goal, GI [gastrointestinal] bypass surgery offers a novel endpoint: the concept of complete disease remission.” Yet the physicians were also decidedly wary about rushing the procedure into common use without clinical trials that might explain its mysterious effect.

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Counting Down to Surgery

For a diabetic to qualify for gastric bypass surgery, just how high does her body mass index need to be?


1. “Laparoscopic Treatment of Type 2 Diabetes Mellitus for Patients With a Body Mass Index Less Than 35,” by A. L. DePaula et al., Surgical Endoscopy, Aug. 18, 2007. Brazilian surgeons describe their gastric bypass procedures on 39 patients, most of whom were not obese but all of whom had chronic type 2 diabetes. A stunning 86.9% of patients had normal blood sugar levels after surgery.

2. “Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery Executive Report,” by George L. Blackburn et al., Betsy Lehman Center for Patient Safety and Medical Error Reduction, December 2007. This comprehensive study examines the rising prevalence of bariatric surgery, improvements in safety and challenges to be met.

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