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Diabetes Management Can Bariatric Surgery be Considered Standard Therapy to Treat Type 2 Diabetes? Karen Meyvis, 1 Christophe De Block 2 and Luc F Van Gaal 3 1. Endocrinologist; 2. Associate Professor of Medicine; 3. Professor of Medicine and Head, Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, University of Antwerp, Belgium Abstract With the rapid increase in obesity there has been a pronounced increase in obesity-related metabolic disorders including type 2 diabetes, cardiovascular disease, dyslipidaemia and hypertension. Bariatric surgery is a highly effective treatment for achieving long-term weight loss and is increasingly recognised to have benefits in diabetes treatment and cause improvement in other metabolic factors. Recent small randomised trials reported better glycaemic control after surgical intervention compared to pharmacological therapy. Physiological studies suggest a surgery-specific, weight-independent effect on glucose homeostasis. Long-term efficacy is to be proven. Consensus on definition of diabetes and diabetes remission must be achieved. Larger multicentre, randomised trials need to be done to clarify the place of metabolic surgery in diabetes treatment algorithms. Keywords Bariatric surgery, type 2 diabetes, body mass index, remission of diabetes, gastric bypass Disclosure: The authors have no conflicts of interest to declare. Received: 16 June 2013 Accepted: 16 July 2013 Citation: European Endocrinology, 2013;9(2):86–91 Correspondence: Luc F Van Gaal, Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, University of Antwerp (UA), Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem, Belgium. E: luc.van.gaal@uza.be Obesity has become an increasingly important health problem. According to estimations of the World Health Organization, the worldwide prevalence of obesity has more than doubled between 1980 and 2008. In 2008, 10 % of men and 14 % of women in the world were obese (body mass index [BMI] ≥30 kg/m 2 ), compared with 5 % of men and 8 % of women in 1980. 1 With the rapid increase in obesity there has been a pronounced increase in obesity-related metabolic disorders including type 2 diabetes, cardiovascular disease, dyslipidaemia and hypertension. 2 Type 2 diabetes is a multi-factorial disorder and obesity is considered the most important risk factor. The prevalence of obesity among adults with diagnosed diabetes is over 50 %, and the prevalence of overweight is over 80 %. 3 It has been estimated that the risk of developing type 2 diabetes is increased 93-fold in women and 42-fold in men who are severely obese (BMI ≥ 35 kg/m 2 ) rather than of healthy weight. 4,5 course requires a continuous monitoring and intensification of the therapy with adding new pharmacological agents. Unfortunately, a number of hypoglycaemic agents, including insulin, sulphonylurea and thiazolidinediones exacerbate weight gain. In the long term, all conservative medical and lifestyle treatments of obesity often fail to achieve sufficient blood glucose control in morbidly obese patients. The mean maintenance weight loss after conservative interventions for obesity is <25 % after 2 years. 9 Bariatric surgery is a highly effective treatment for achieving long-term weight loss in adults with obesity. 10 Moreover, bariatric surgery is increasingly recognised to have benefits in diabetes treatment and can also be associated with improvements or normalisation in blood pressure, lipid profile, quality of life and obstructive sleep apnoea syndrome. 11 Types of Bariatric Surgery and Indications Given this information, weight loss is one of the most important treatment strategies to obtain good glycaemic control (glycated haemoglobin [HbA 1c ] <7  %). Intentional weight loss of at least 5  % to 10  % of body weight has repeatedly been shown to improve glycaemic control and cardiovascular risk profiles in obese subjects with type 2 diabetes. 6–8 Type 2 diabetes is usually a progressive disease characterised by both a loss of insulin secretory capacity of the pancreatic ß-cells over time and insulin resistance, resulting in progressive hyperglycaemia and subsequent micro- and macrovascular complications. This natural 86 The disappointing results of medical treatments, along with the growing incidence of obesity and its related life-threatening complications, has led to the widespread use of bariatric surgery. In the past, different possible surgical procedures were developed to achieve weight loss. The most commonly used bariatric procedure worldwide in 2011 was Roux-en-Y gastric bypass (RYGB) (46.6 %). Sleeve gastrectomy accounted for 4.5  % of the bariatric procedures in 2008, while the number of this type of bariatric procedure increased to 27.8 % in 2011. Adjustable gastric banding (AGB) was performed in 17.8  %, © Touch ME d ica l ME d ia 2013