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Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: a Joint Statement by International Diabetes Organizations

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Abstract

Background

Despite growing evidence that bariatric/metabolic surgery powerfully improves type 2 diabetes (T2D), existing diabetes treatment algorithms do not include surgical options.

Aim

The 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference, was convened in collaboration with leading diabetes organizations to develop global guidelines to inform clinicians and policymakers about benefits and limitations of metabolic surgery for T2D.

Methods

A multidisciplinary group of 48 international clinicians/scholars (75% nonsurgeons), including representatives of leading diabetes organizations, participated in DSS-II. After evidence appraisal (MEDLINE [1 January 2005–30 September 2015]), three rounds of Delphi-like questionnaires were used to measure consensus for 32 data-based conclusions. These drafts were presented at the combined DSS-II and 3rd World Congress on Interventional Therapies for Type 2 Diabetes (London, U.K., 28–30 September 2015), where they were open to public comment by other professionals and amended face-to-face by the Expert Committee.

Results

Given its role in metabolic regulation, the gastrointestinal tract constitutes a meaningful target to manage T2D. Numerous randomized clinical trials, albeit mostly short/midterm, demonstrate that metabolic surgery achieves excellent glycemic control and reduces cardiovascular risk factors. On the basis of such evidence, metabolic surgery should be recommended to treat T2D in patients with class III obesity (BMI ≥40 kg/m2) and in those with class II obesity (BMI 35.0–39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy. Surgery should also be considered for patients with T2D and BMI 30.0–34.9 kg/m2 if hyperglycemia is inadequately controlled despite optimal treatment with either oral or injectable medications. These BMI thresholds should be reduced by 2.5 kg/m2 for Asian patients.

Conclusions

Although additional studies are needed to further demonstrate long-term benefits, there is sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with T2D and obesity. To date, the DSS-II guidelines have been formally endorsed by 45 worldwide medical and scientific societies. Health care regulators should introduce appropriate reimbursement policies.

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Authors and Affiliations

  1. King’s College London, London, UK

    Francesco Rubino & Stephanie A. Amiel

  2. Harvard Medical School, Boston, MA, USA

    David M. Nathan & Lee M. Kaplan

  3. University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Robert H. Eckel

  4. Cleveland Clinic, Cleveland, OH, USA

    Philip R. Schauer

  5. Imperial College London, London, UK

    K. George M. M. Alberti

  6. Monash University, Melbourne, Victoria, Australia

    Paul Z. Zimmet

  7. University of Pisa, Pisa, Italy

    Stefano Del Prato

  8. Peking University, Beijing, China

    Linong Ji

  9. Diabetes India, Mumbai, India

    Shaukat M. Sadikot

  10. University of Michigan, Ann Arbor, MI, USA

    William H. Herman

  11. Philadelphia, PA, USA

    Gaspar Taroncher-Oldenburg

  12. University of Washington, Seattle, WA, USA

    David E. Cummings

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  1. Francesco Rubino
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Consortia

on behalf of the Delegates of the 2nd Diabetes Surgery Summit

Corresponding authors

Correspondence to Francesco Rubino or David E. Cummings.

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Funding and Duality of Interest

The DSS-II and WCITD 2015 were supported by the International Diabetes Surgery Task Force (a nonprofit organization), King’s College London, King’s College Hospital, Johnson & Johnson, Medtronic, Novo Nordisk, Fractyl, DIAMOND MetaCure, Gore, MedImmune, and NGM Biopharmaceuticals. These sponsors played no role in the selection of voting delegates, the Delphi process, the DSS-II and WCITD 2015 programs, or the writing of this article. None of the DSS-II codirectors, members of the organizing committee, or voting delegates received payment for their efforts. No other potential conflicts of interest relevant to this article were reported.

Additional information

F.R. and D.E.C. chaired the writing committee for this report.

The 2nd Diabetes Surgery Summit voting delegates are listed in Table 2.

Copyright © 2016 American Diabetes Association from: Diabetes Care 2016 Jun; 39(6): 861-877. Reprinted with permission from The American Diabetes Association

See accompanying articles, pp. 857, 878, 884, 893, 902, 912, 924, 934, 941, 949, and 954 in Diabetes Care 2016 Jun; 39(6).

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Rubino, F., Nathan, D.M., Eckel, R.H. et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: a Joint Statement by International Diabetes Organizations. OBES SURG 27, 2–21 (2017). https://doi.org/10.1007/s11695-016-2457-9

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