Diabetes and Bariatric Surgery

There is a recent article in the New York Times with a very provocative title, “Before You Spend $26,000 on Weight-Loss Surgery, Do This” aimed at those who believe that bariatric surgery is now the best option for diabetics.

This is because of the new 2016 guidelines endorsed by a group of clinicians and researchers (75% of them non-surgeons) that advocate the use of bariatric surgery in the treatment of type II diabetes.

This is also because of the general thinking that lifestyle intervention does not help much over a long period of time.

However, there is growing data that suggests that a low carb diet without caloric restriction can go a long way in helping to control HbA1c levels. The New York Times article by Sarah Hallberg and Osama Handy essentially focuses on this and ends with this quote “We owe our patients with diabetes more than a lifetime of insulin injections and risky surgical procedures. To combat diabetes and spare a great deal of suffering, as well as the $322 billion in diabetes-related costs incurred by the nation each year, doctors should follow a version of that timeworn advice against doing unnecessary harm — and counsel their patients to first, do low carbs.”

This cannot be more relevant in the Indian context. As of 2015, there were 69 million adults with diabetes in India with 1 million deaths per year. Essentially one in 11 adults in India has diabetes.

I reached out to Dr. Roshani Sanghani , an endocrinologist trained in the US, working specifically with diabetics, who runs Aasaan Health.

“This article is very relevant for for the Indian context. The average Indian consumes a carbohydrate rich diet and pays for his/her healthcare out-of-pocket. Everyday I see patients with type 2 diabetes and obesity who eat more carbohydrates than their bodies can handle. Prescribing the latest drugs and offering complicated surgeries are options available to us as doctors, but these options cannot be used in good conscience if we do not advocate the power of reducing carbohydrate intake. “

“I have treated patients of varying ages, cultures and education levels who came with uncontrolled diabetes requiring prescriptions of two or three different tablets (or at times, insulin). By learning Diabetes Self-Management, many who had long-standing type 2 diabetes were able to self adjust their carbohydrate intake, which allowed me to reduce the medication burden and quite often, stop their insulin.”

“It is not true that diabetes prescriptions need to keep getting longer and costlier. Type 2 diabetes can certainly be reversed to a larger extent by lifestyle change than most healthcare providers make centre-stage. I cringe at the word  “low carb diet”  because that makes it sound like it’s a set of rules that needs to be prescribed to patients, and that further might imply the patients need to follow my rules indefinitely. “

“We as doctors can support much more empowering and long-lasting behaviour change when patients start monitoring their own blood glucose levels, and learn to take the responsibility of changing their diet in a way that suits them.”

“Instead of unilaterally telling patients to “stop eating so many carbs”, encourage them to first, figure out why they are eating so many carbs and second, notice the difference in their hunger, energy and blood sugar levels in the “high carb + low protein + low vegetables” versus “low carbohydrate + adequate protein + adequate vegetables” menus. This keeps the solutions and decisions in the hands of the individual which results in more sustainable behaviour change. Think about it: how did it go the last time you kept doing something you didn’t want to do?”

In short, before advocating costly drugs, insulin, bulimia tubes and bariatric surgery, perhaps a little change in lifestyle and diet might go a long way in making a huge difference to the management of diabetes.