The Northern Ireland Audit Office Report “Type 2 diabetes; prevention and care” published on Tuesday 6th March is critical of DoH’s failures in both creating and implementing policy for Type 2 Diabetes. Type 2 Diabetes is an important disease because; it is common (6% of the population and rising), is generally progressive (the speed of which is inversely proportional to how well it is controlled), is very costly to manage (£400 million a year or 10% of health budget), and it ultimately makes the lives of those who suffer from it pretty miserable when left to its own devices (blindness, kidney failure, amputation) which sadly is all too often.
Its cause is mainly lifestyle with obesity accounting for about 80% of all new cases yet this makes it eminently preventable with a 60% reduction in incidence when people adopt small changes in what they eat and how much they exercise. We are not talking serious lifestyle changes here just reducing body weight by 10% through healthy eating and moderate exercise. Oh, and it’s curable if action is taken early enough. With a 70% increase in the last 15 years, the NIAO is right to point out when it comes to Type 2 Diabetes we are failing miserably.
The failures, of course, are not exclusively the DoH’s. A lot is down to the individual, the family and local communities and their failure to adopt norms that protect against the rise in diabetes. Yet there seems to be a patronising attitude, sub-conscious I trust, at DoH which exhibits a certain contempt for those who have, in the view of some of our mandarins, brought the condition on themselves. Perhaps this might explain why little real investment has been made in prevention support and also explains the disdain that emanates from civil servants on any suggestion that we need to locally commission gastric surgery for the obese.
Yet, in addition to the clear benefit from prevention services, there exists compelling evidence that surgery for obese people provides medically significant weight loss over time that both reverses Type 2 Diabetes in those suffering from the condition and prevents it in those who do not yet have it. Don’t you believe me? Eight thousand obese patients who had undergone gastric bypass surgery were compared with matched controls for age, gender and Body Mass Index. Follow up for an average of 7.1 years showed that those in the surgery group were 25% less likely to have died. A second study followed 14,000 patients after two bariatric surgical procedures and found that there was a mean loss of 53% of excess weight for vertical banded gastroplasty and a 72% mean loss for gastric bypass surgery.
There will always be a trade-off between the risks of surgery and the consequences of lifelong obesity and associated complications. Yet the risks associated with bariatric surgery have decreased in recent years.
Bariatric surgery –the medical term for cutting the stomach – is extremely successful in inducing long-term weight loss because the intervention is considered to be, (and almost always is) permanent, which dramatically reduces the risk of rebound weight gain. A successful procedure may induce a reduction of approximately 50-60% of excess body weight during the first 12-24 months; a person weighing 300lb might realistically expect to achieve a weight loss of 100lb. That’s impressive.
The Swedish Obese Subjects (SOS) cohort study is the best-known study of bariatric surgery. It began in 1987 and ultimately included over 4,000 patients. The primary aim of the SOS study was to discover whether there is a reduction in death with intentional weight loss; secondary aims were to examine the effects of weight loss on specific factors such as heart disease and type 2 diabetes, health-related quality of life and health economics.
This study, and other trials has demonstrated more than a 75% to a 90% resolution rate of type 2 diabetes, 66% resolution for hypertension, and improvements in; cholesterol, stress incontinence, sleep apnoea, ankle oedema, and resumption of regular menstruation. The chance of later development type 2 diabetes where the obese patient was not diabetic, was also noted. Surgery is prevention and cure.
The “curing” of type 2 diabetes by gastric surgery is as impressive as it is mysterious. An obese patient newly diagnosed with Type 2 Diabetes who gets most of his or her stomach cut away gets reversal of diabetes very quickly before any real weight loss is achieved. This suggests some, as yet unidentified, system at play which is removed in the surgery reversing the condition.
A point made in the NIAO reports was that if N. Ireland complied with the NICE guidance on bariatric surgery then some 50,000 local residents would be eligible. It is likely that perhaps only 3% of this group would ever consider it but 1,500 is better than the 120 who get surgery in England annually at a cost of £1.5 million. We already perform some 150 amputations a year due to poorly controlled diabetes and each of these operations attracts a similar cost to stomach bypass surgery.
In an ideal world, the public would heed the call to eat a better diet and take more exercise but there seems to be little appetite for this. It is radical to suggest we invest say £20 million in gastric surgery for the obese and do this as a means of managing, preventing and “curing” Type 2 Diabetes but reading the NIAO report it seems this offers much better value for money than the current failing approach which has the potential to eventually bankrupt our health service.