Web-based Tool to Help Assess Diabetes Outcomes With and Without Surgery

with Ali Aminian, MD, and Caroline Apovian, MD

For those of you who have type 2 diabetes with obesity or have a family member that does, one of the best ways to reduce common health risks such as heart disease and stroke is by having gastric bypass surgery.

The reason for this seems to be that metabolic surgery—any procedure that changes the function and structure of the stomach or small intestine—supports weight loss, leading to improvements in glucose control and insulin sensitivity; and, ultimately diminishes the complications associated with diabetes. Still, how can you be sure that surgery is the right way to go?

You can now learn how beneficial gastric bypass surgery is for you specifically.Cleveland Clinic researchers have developed a risk assessment tool to give you a sense of your health risks for diabetes complications in the decade ahead if you do or don't have bariatric surgery. Photo: fstop123 @ iStock

Recognizing that surgery is a daunting step for some and represents too much uncertainty for others, a web-based risk assessment calculator was created by a team of investigators at the Cleveland Clinic in Ohio to help you to determine if bariatric surgery will favorably improve your long-term health.2,3 The results can be shared with your health provider as a starting off point in discussing a disease management plan now and going forward.

This predictive tool is intended to guide you and your doctor to understand the long-term medical risks associated with type 2 diabetes (T2D) and obesity, and to consider the benefits you might gain from having this surgery,2 says Ali Aminian, MD, a bariatric surgeon at the Cleveland Clinic who presented the research supporting development of this tool at a session during ObesityWeek 2019, in Las Vegas, Nevada.

Process for Developing a Diabetes Treatment Assessment Tool

Dr. Aminian outlined the development of the risk calculator. He and his team evaluated the experiences of 13,722 patients with both diabetes and obesity—comparing patients who underwent bariatric surgery as compared to closely matched individuals who were eligible for surgery but chose to continue with their standard medical treatment.2

After following these patients, the individuals who elected to have surgery proved to have a lower risk for every one of the five common complications associated with diabetes. These included: heart disease, stroke, heart failure, kidney disease, and death from all causes.2

Across the board, following these gastric procedures, individuals had a lower risk of every diabetes-related risk. Unfortunately, fewer than 1% of the patients who were eligible for bariatric surgery have it,3 he says.

The researchers than gathered relevant data from the medical records of nearly 290,000 patients with obesity who were being treated for type 2 diabetes in the Cleveland Clinic Health System from 2004 to 2007. Health measures including age, sex, body mass index (BMI), diabetes-related complications, and medications taken were combined to determine patient-specific risks. The researchers also incorporated levels of hemoglobin A1c, blood pressure, and blood cholesterol levels.3

The data supporting the impact of weight-loss surgery on complications of type 2 diabetes, such as stroke and heart disease as well as kidney disease, was published in the Journal of the American Medical Association.2 The results support use of the risk calculator since the data indicated that patients who had metabolic surgery were 39% less likely to experience conditions such as heart disease, stroke, or diabetic kidney disease and 41% were less likely to die from any cause.2,3

When used by an individual, the risk assessment tool can help give both patients and providers a 10-year disease probability of developing the life-threatening complications related to diabetes if the current path is continued, as well as a comparison should you choose to undergo bariatric surgery.

How Effective Is the Gastric Bypass Risk Assessment Tool? As the Individualized Diabetes Complications (IDC) risk calculator was only just released, there hadn’t been enough time to gather feedback yet, Dr. Aminian tells EndocrineWeb. However, he has already heard from several enodcrinologists, cardiologists, and primary care providers that they intend to use the calculator in their practices.

Diabetes Risk Assessment Tool Promises to Better Treatment Planning 

According to Caroline Apovian, MD, of Boston University School of Medicine, the reason for greater disease complications stems from a failure of primary care physicians and endocrinologists to recommend more eligible patients discuss their status with a bariatric surgeon. This risk calculator will help not just patients but also providers to realize the benefits of gastric surgery beyond weight loss, and to recognize the risks of not choosing to have surgery, she says.

While there isn’t currently a way to determine which bariatric procedure would be best for each individual, Dr. Apovian tells EndocrineWeb, there are studies that indicate that the Roux-en-Y Gastric Bypass offers the best effect on hormone levels.4-6 Dr. Aminian acknowledges that despite the limitations of the risk assessment tool— as it doesn’t include information on family history of heart disease or length of time with type 2 diabetes—which would be helpful in addressing patient risk, the results derived by the IDC assessment are still valid.2,3

“These gastric procedures are very powerful and safe methods for treating individuals with both obesity and type 2 diabetes,” says Dr. Aminian. “Having surgery can provide significant weight loss, improve diabetes, cholesterol levels, delivering a survival benefit as well as improved quality of life.” Even though treating these patients with bariatric surgery is known to be beneficial, a lack of access to trained surgeons and the stigma associated with any method of weight loss besides diet and exercise, has made this option less desirable, he says.

Dr. Apovian has already made use of the ICD assessment tool in her practice “It adds a spotlight that can help patients to better grasp the benefits to surgery.”

In another presentation delivered at ObesityWeek 2019 in Las Vegas, Nevada, Oliver Varban, MD, associate professor of surgery including bariatric procedures in the University of Michigan Health System in Ann Arbor, presented data supporting the value of sleeve gastrectomy for individuals who have mild obesity (ie, body mass index [BMI] < 35 kg/m2).7 In this study of more than 45,000 patients, achieving a normal BMI occurring more often in patients with a starting BMI below 35 than above who also voiced greater satisfaction with the procedure.

In a press statement, Dr. Varban said: “We hope the study encourages more patients to consider weight loss surgery earlier in their disease and for more health insurers to recognize the benefits of lowering the current BMI-threshold.”

Surgery Should be Considered by Many More Patients to Address Type 2 Diabetes

Indeed, it is most constructive for providers to introduce patients to this surgical assessment tool to help illuminate the risks individuals likely face in avoiding bariatric surgery, says Dr. Apovian. She anticipates that providers and patients might use the ICD tool together in an office setting when considering the need for treatment to improve outcomes and better manage type 2 diabetes with obesity.

Both physicians and patients still fail to treat obesity as a disease, says Dr. Apovian, raising a long-held observation. Too many doctors still view obesity as a matter of willpower and self-control, expecting patients alone to carry full responsiblity for losing weight. “There is need for the medical community to acknowledge that obesity is a malfunction of metabolic pathways driving hunger and satiety talk between the gut and the brain.”

Any educational tool that offers to dispel this old way of thinking is very welcome, says Dr. Apovian, as we need to help change attitudes so obesity can be approached as disease in need of medical intervention.

Tool Isn’t Perfect, Yet Creates Discussion Starter for T2D Treatment Pros & Cons  

In the future, having more information included in the tool on who will develop heart disease – on a genetic level – could help patients and providers better target particular treatments to specific people.

The assessment algorithm doesn’t allow for influences that may change the results based on demographic information such as race and ethnicity.2 Dr. Apovian has studied the impacts of surgery on different populations, and recently published data that showed that African American and Latino populations don’t respond as well as Caucasians to metabolic surgery and are more likely to relapse into diabetes.4

Knowing the reasons for variability in outcomes based on racial differences could assure a more accurate and wider use of the ICD assessment tool but such developments still need more time in the academic incubator.2

More data on the type of surgery and outcomes across subpopulations would be good, says Dr. Apovian, particularly as sleeve gastrectomy produces a different impact on hormones related to satiety then the Roux-en-Y gastric procedure. “We are starting to see conversions to Roux-en-Y after failed sleeve surgeries,” she says.

“As for the ICD tool, I’d love to see all practitioners using this in their practices,” says Dr. Apovian. “It introduces sound numbers to the conversation with patients, and if that helps doctors convert more patients to opt in to surgery, then that will be great.”

The Cleveland Clinic research received a research grant from Medtronic.

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