DIABETES/METABOLISM RESEARCH AND REVIEWS
Diabetes Metab Res Rev 2004; 20: 438–445.
Published online 23 August 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/dmrr.507
Obesity, bariatric surgery and type 2 diabetes –
a systematic review
Cynthia V. Ferchak*
Luigi F. Meneghini
Kosow Diabetes Treatment Center,
Diabetes Research Institute of the
University of Miami School of
Medicine, Miami, FL, USA
*Correspondence to: Cynthia V.
Ferchak, Diabetes Research Institute
of the University of Miami School of
Medicine, Miami, FL, USA.
E-mail: cferchak@med.miami.edu
Received: 17 September 2003
Revised: 23 April 2004
Accepted: 24 May 2004
Copyright  2004 John Wiley & Sons, Ltd.
REVIEW ARTICLE
Summary
Obesity is endemic in the United States and is closely linked to the
development of type 2 diabetes. Both obesity and diabetes are responsible for
significant morbidity and mortality. Likewise, both conditions are resistant to
treatment. Recent studies have evaluated prevention of type 2 diabetes
through intensive lifestyle intervention, while others are examining the
impact of bariatric surgery on type 2 diabetes. This article presents an
overview of the impact of bariatric surgical and lifestyle interventions on
the prevention and treatment of type 2 diabetes. Although studies using a
variety of bariatric surgical techniques are included, the focus is on two
interventions in particular: the Roux-en-Y gastric bypass and the laparoscopic
silicone gastric banding procedure. Outcomes of these procedures are further
contrasted with recent lifestyle intervention studies, in particular, the Diabetes
Prevention Program study. Gastric bypass studies have been associated with
a 99 to 100% prevention of diabetes in patients with IGT and an 80 to
90% clinical resolution of diagnosed early type 2 diabetes. Gastric banding
procedures are associated with a lower median (50–60%) clinical remission of
type 2 diabetes. Lifestyle intervention studies of obese and glucose-intolerant
patients have achieved a 50% reduction in the progression of IGT to diabetes
over the short term, with no reported resolution of the disease. Weight loss
by any means in the obese patient appears to prevent progression to type
2 diabetes, at least in the short term. Furthermore, sustained weight loss
through bariatric surgical intervention is associated both with prevention
of progression of IGT and with clinical remission of early type 2 diabetes.
Copyright  2004 John Wiley & Sons, Ltd.
Keywords bariatric surgery; type 2 diabetes; diabetes prevention; obesity;
weight loss
Introduction
Obesity is a major risk factor for the development of type 2 diabetes mellitus.
Conversely, weight loss in the overweight or obese patient can delay or even
prevent the onset of diabetes in individuals with pre-diabetes or impaired
glucose tolerance (IGT), and significantly improve blood glucose control in
patients with type 2 diabetes [1,2]. Although aggressive treatment of type 2
diabetes has clearly been shown to reduce related morbidity and mortality
and improve long-term quality of life [3], the management of type 2 diabetes
and obesity can be a frustrating experience to both patient and physician. In
spite of numerous therapeutic strategies available to control type 2 diabetes,
the ADA–mandated (American Diabetes Association) goal of HbA1c < 7% is
achieved by less than half of patients with diabetes [4]. And notwithstanding
an arsenal of weight-loss schemes and products, most weight-loss inter-
ventions usually fail to achieve sustainable weight reduction. This realization
Obesity, Bariatric Surgery and Type 2 Diabetes
has led to consideration of more invasive interventions.
Following years of experience and modifications in
technique, weight-loss (bariatric) surgery is beginning
to gain acceptance as a therapeutic option. Mounting
evidence documents that surgically induced weight loss
has a favorable and, more importantly, sustainable effect
on body weight and consequently on type 2 diabetes.
The greatest benefit with regard to glycemic control is
often obtained early in the disease process when weight
loss is achieved before beta cell function is permanently
impaired [5–8].
Methods
A Medline Boolean search was done using the keywords
‘diabetes’ and ‘bariatric surgery’, from 1990 to 2003.
Eighty-two publications were obtained. From these were
selected studies that had pre- and post-surgical data,
which included measurable glycemic endpoints. Although
studies using a variety of bariatric surgical techniques are
included, the focus is on two interventions in particular:
the Roux-en-Y gastric bypass and the laparoscopic silicone
gastric banding procedure. Outcomes of these were com-
pared with the outcomes of lifestyle intervention studies.
Treatment options for obesity
Diet and exercise have been the traditional mainstays of
weight-loss treatment. Even when enhanced by behavior
modification programs and anti-obesity drugs, most
medical/behavioral intervention results in only 5 to 10%
loss of excess weight, and the cumulative relapse rate
is almost 100% at 5 years [9,10]. Indeed a NIH 1991
consensus report noted that ‘a major drawback to the
non-surgical approach to obesity is failure to maintain
reduced body weight in most patients’ [11], yet weight-
loss failure is often perceived as patient failure rather than
treatment failure by both patient and practitioner.
In a study of patient expectations, Foster and
coworkers [12] polled overweight patients regarding
their perception of desirable weight loss and reported
that participants considered an average weight reduction
of 25 to 32% as desirable or acceptable, while a 17%
weight loss was considered ‘disappointing’. Considering
that the average weight loss using traditional therapies
is approximately 5 to 10% [7], it becomes clear that
patient expectations will rarely be attained, let alone
maintained, with current non-surgical interventions. The
real significance of surgical intervention for obesity,
however, is the accumulation of data, which indicates
not only considerable and sustained weight loss following
bariatric surgery but also the associated resolution of
obesity-related complications.
Surgical procedures for the treatment of obesity have
been considered since the 1950s [13], among them,
truncal vagotomy [14], jaw wiring [15], intragastric
balloons, lipectomy, and liposuction. More recently,
Copyright  2004 John Wiley & Sons, Ltd.
439
several methods of bariatric surgery have been the focus
of numerous studies and modifications in technique to
improve associated surgical risk. The 1991 NIH Consensus
Statement [11] recommended two types of surgery for the
treatment of morbid obesity: Vertical Banded Gastroplasty
(VBG), a purely restrictive procedure, and Roux-en-
Y gastric bypass (GBP), a combined gastric restrictive
and malabsorptive procedure. More recently, since FDA
approval in 2001, the laparoscopic adjustable silicone
gastric banding technique (LASGB) has replaced VBG
as the most commonly used restrictive procedure [16].
Compared to the average 5 to 10% weight loss seen
following non-surgical interventions, bariatric surgery is
able to achieve 20 to 50% weight loss, with greater
likelihood of maintaining that weight loss over time
[7,17].
Gastric bypass employs two strategies for weight
reduction: gastric restriction, involving the reduction
of stomach volume in order to promote early satiety,
along with intestinal malabsorption in which the small
intestine is shortened to decrease nutrient absorption. The
Roux-en-Y Loop bypasses the duodenum, and part of the
jejunum. The length of bypassed intestine can be adjusted
according to the desired amount of malabsorption and
consequent weight loss (Figure 1).
Some of the modifications in the procedure, which
have resulted in better surgical outcomes, include gastric
division rather than gastric partition, using the lesser
curvature for the pouch rather than the more stretchy
fundus, using a minimal pouch size of 15 cc, with the
assumption that it may dilate by as much as 100% over
time, and over-suturing staple lines to prevent breakdown
and leakage [18].
The open Roux-en-Y is now being replaced by a
laparoscopic approach. As with all laparoscopic surgery,
this results in a shorter post-operative recovery with an
earlier return to normal activity, along with fewer wound
complications such as infections, hernias, and wound
dehiscence. Several large studies of the laparoscopic
Roux-en-Y gastric bypass technique have shown that
the laparoscopic procedure can, with experience, be
undertaken safely and effectively, even in morbidly obese
patients, and in patients who have had prior abdominal
surgery [19,20].
Reduced
gastric pouch
Bypassed
intestine
Figure 1. Roux-En-Y gastric bypass
Diabetes Metab Res Rev 2004; 20: 438–445.
440
Restricted
stomach volume External access
port
Saline-filled
band
Figure 2. Lap-Band
The LASGB on the other hand, is a purely restrictive
procedure that involves encircling the upper part of the
stomach with a band-like, saline-filled tube (Figure 2).
The benefit of the procedure is its relative technical ease.
Unlike earlier purely restrictive procedures, there is no
incision or stapling of the stomach required, and being a
laparoscopic technique, there are fewer perioperative risks
involved. The possibility for non-surgical adjustments of
stoma size is another advantage. The saline-filled tube
can be deflated percutaneously without further surgery
in case of problems such as vomiting and esophageal
enlargement, or, conversely, inflated if the patient stops
losing weight.
Complications
A major issue in discussions about bariatric surgery is
whether the surgery is safe. Like any major operation,
bariatric surgery carries risks, including the possibility
of complications from general anesthesia and infections.
Most perioperative morbidity is the result of wound
infection and cardiopulmonary dysfunction. In one of the
important early studies of 608 morbidly obese patients
undergoing open gastric bypass, many of whom were
already seriously ill, the perioperative mortality was
reported at 1.5% with a complication rate of 8.5% [5].
With improvements in technique, the mortality rate is
now less than 1% [21]. Table 1 provides a summary of
the major complication rates seen with bariatric surgery.
The laparoscopic approach to any surgery offers poten-
tial reduction in perioperative morbidity, in particular,
cardiopulmonary morbidity. Patients are able to ambulate
Table 1. Complication rates for mixed bariatric procedure types
[21]
Mortality <1%
Leakage/peritonitis <1%
Venous thromboembolism <1%
Respiratory complications <2%
Staple line failure 2–5%
Wound problems 15%
Incisional hernias <25%
Gallstones 36%
Nutritional deficiency <40%
Copyright  2004 John Wiley & Sons, Ltd.
C. V. Ferchak and L. F. Meneghini
sooner and more comfortably, thus reducing the risk of
DVT and fatal pulmonary embolism. Studies have shown
that laparoscopic approaches are not contraindicated in
patients with previous abdominal surgery, and that it is
the better approach to avoid adhesions [22,23].
In addition to the usual risks of surgery in the
obese patient, some complications are specific to the
type of procedure. The Roux-en-Y bypass is associated
with nutritional deficiencies such as iron, folate and
B12 malabsorption, calcium deficiency, and osteoporosis,
as well as an increased risk of stomach ulceration
(3–15%). Gastric bypass can also cause a dumping
syndrome. The LAPSB has had significant problems with
band erosion or slippage, band leakage, and esophageal
dilatation. It has been estimated that there is a 7
to 15% incidence of re-operation for complications
associated with the LAPSB, although this appears to
be declining with additional clinical experience [22,23].
With either bariatric procedure, the brisk weight loss is
associated with an increased risk of gallstones, which
can be prevented by prophylactic cholecystectomy or
administration of ursodiol post-operatively.
Type 2 diabetes is one of the most serious complications
of obesity, and the use of bariatric surgery to achieve and
maintain weight loss in patients with or at risk for diabetes
is of particular interest, given the epidemic of obesity with
related metabolic abnormalities in our country.
A recently published ADA Position Statement on the
prevention of type 2 diabetes [25] cited four well-
controlled, randomized studies that showed a significant
reduction in the incidence of diabetes via lifestyle
intervention (weight loss and exercise) and a less but
still significant reduction associated with pharmacological
intervention [2,26–28]. All of the studies were relatively
short term with an average follow up of 2.9 years, and the
achieved weight loss through the two lifestyle intervention
studies was only 5 and 7%, respectively, and was attained
by only 43% of the intervention group in one study and
50% in the other [2,26]. While this amount of weight loss
did correlate with a decreased incidence in progression of
IGT to diabetes, it is not known for how many years the
weight loss and the effort to sustain it can be maintained
and if it will be sufficient to prevent future development of
hyperglycemia. The lifestyle intervention groups in these
studies ‘required substantial effort . . . to achieve modest
changes in weight and exercise’ [26], a fact that severely
limits applicability outside of a research trial.
Studies of the use of bariatric surgery in patients with
or at risk for diabetes have shown that not only can
surgically induced weight loss prevent progression from
IGT to diabetes, but in many cases results in clinical
remission of type 2 diabetes.
Long et al. [6], in a non-randomized, controlled study,
followed 136 subjects with IGT and morbid obesity
(>45 kg excess body weight) for an average of 5.8
(range 2–10) years. Of these, 109 patients underwent
open gastric bypass surgery for weight loss, while 27
subjects elected not to have surgery but agreed to be
followed for at least 2 years and serve as the control
Diabetes Metab Res Rev 2004; 20: 438–445.
Obesity, Bariatric Surgery and Type 2 Diabetes
group. Whereas 6 patients (22%) from the control group
developed diabetes, only one patient (0.9%) from the
surgical group did. Although this patient lost weight after
surgery, the weight was later regained.
Pories and colleagues [5] followed 608 morbidly obese
patients for 14 (average 7.6) years after open gastric
bypass surgery. Average excess weight loss at the end
of the study was 49% (range 7–81%). Of the 608
patients, 330 patients had either diabetes (n = 165) or
IGT (n = 165) at baseline. Of these, 298 were followed
for up to 14 years post surgery. Remarkably, while 98.7%
of patients with IGT remained euglycemic, a full 82%
of those with type 2 diabetes (121/146 patients) had
normal HbA1c at study end. Review of the 27 patients
who did not achieve euglycemia showed that 10 had
experienced staple line breakdown. The remaining 17
non-responders were older (48.0 vs. 40.7 years; p < 0.01)
and had diabetes of longer duration (4.6 vs. 1.6 years;
p < 0.04) than those who either did not progress to
diabetes or those who went into remission.
Although these initial reports documented a substantial
benefit of gastric bypass surgery on type 2 diabetes
or IGT, it was still not clear whether there was a
concurrent reduction in long-term mortality. Another
study by the same group [29] examined the effect
of gastric bypass surgery on long-term mortality rates
as well as on glycemic control in 232 morbidly obese
patients with type 2 diabetes, 154 of whom underwent
bariatric surgery. The mortality rate in the control group
(22/78) was significantly higher (p < 0.0003) than that
in the surgical group (14/154). The greatest difference
between the groups was attributed to cardiovascular
deaths, with 12 events occurring in the control group
(54.5%) compared to only 2 deaths in the surgical
group (14.3%). In the surgical group, the most common
cause of death (28%; 4/14) was perioperative mortality
due to 2 deaths from pulmonary emboli, 1 from sepsis
secondary to staple-line leakage, and the last from an
unknown cause after discharge. The overall perioperative
mortality rate for the entire 154 surgical patients
was 2.6% (4/154). During the course of this study,
gastric bypass surgical techniques underwent several
modifications. With newer laparoscopic techniques, the
American Society for Bariatric Surgery currently reports a
perioperative mortality rate of less than 0.2% [30].
Diabetes management was also improved as a result
of surgical intervention for weight loss. Of the 154
patients who underwent GBP, 31.8% were treated with
antiglycemic agents at baseline, compared to 56.4% of
the control group. The patients were followed for up to
14 years, with a mean follow up time of 6.2 years for the
controls and 9 years for the surgically treated group. At
the last contact, antiglycemic medication use in surgical
patients fell to 8.6%, whereas the percent of patients
on drug treatment in the control group increased to
87.5%. The drug remission rate was highly significant for
the surgical group (p = 0.0001), while the progression
rate was statistically significant for the control group
(p = 0.0003). Coincidentally, the mean sustained weight
Copyright  2004 John Wiley & Sons, Ltd.
441
loss in the surgical group was 32%, reflecting a fall from
a preoperative mean weight of 142 kg to a mean weight
of 96 kg at study end.
The Swedish Obese Subjects (SOS) Study [31] is the
largest, long-term, ongoing prospective evaluation of
the use of surgery for intentional weight reduction in
severely obese individuals. Sjostrom et al. [32] followed
767 surgically treated patients and 712 matched controls
for two years in order to assess the impact of surgical
weight loss on comorbidities of obesity including type 2
diabetes. Of the initial 1479 patients, 196 had type 2
diabetes. The two-year unadjusted incidence of diabetes
was 0.2% in the surgical group and 6.3% in the
control group. Among the surgically treated patients,
191 underwent gastric banding, 534 VBG, and 42 GBP.
Weight reduction was somewhat greater in the group
that underwent GBP as compared to the groups that
underwent VBG or gastric banding; at two years, GBP had
resulted in 33 ± 10% weight reduction versus 23 ± 10%
and 21 ± 12% weight reduction in the VBG and gastric
banding groups, respectively.
Subsequently, Sjostrom and colleagues sought to
determine the effect of intentional weight loss lasting at
least 2 years on blood glucose levels, as well as the effect of
weight loss on future risk of diabetes [33]. Three hundred
and forty six patients awaiting gastric surgery (both GBP
and purely restrictive surgical interventions were used)
were matched with 346 obese control subjects who would
not undergo surgery. By self-report, 12.5% of controls
and 9.9% of the surgical cohort had type 2 diabetes at
baseline. Eight-year data was available on 251 (72.5%) of
surgically treated patients and 232 (67.1%) of the control
subjects. While weight in the control group was essentially
unchanged, there was a substantial reduction in weight
in the surgically treated patients with a statistically
significant 20.7-kg difference in weight change between
the surgical and non-surgical groups (p < 0.001). Weight
loss in the surgical group was influenced by the type
of surgery, with the GBP cohort having a somewhat
greater sustained weight loss than the purely restrictive
procedures. At eight years, the gastric bypass cohort
had a mean weight of 90 kg versus a mean weight of
100 kg in the restrictive procedure cohort. The unadjusted
prevalence of diabetes after 8 years was significantly
lower in the surgically treated group than in the control
group (p < 0.001). During the study, the unadjusted
prevalence of diabetes in the control group increased
from 7.8 to 24.9%, whereas the surgically treated group
had an almost stable prevalence of 10.8% at inclusion
and 10.5% at 8 years. Thus, the effect of sustained weight
loss achieved through surgical intervention resulted in a
relative reduction in the development of diabetes over
8 years of observation.
Laparoscopic Adjustable Silicon Gastric Banding
(LASGB) has also been the focus of recent studies. Pon-
tiroli et al. [34] maintain that the LASGB procedure
has similar clinical and metabolic outcomes to those
obtained with gastric bypass surgery. They suggest that
the LASGB procedure is the better choice due to the
Diabetes Metab Res Rev 2004; 20: 438–445.
442
irreversibility, morbidity, and post-operative burden of
gastric bypass surgery. Their study consisted of 143 sub-
jects who underwent the LASGB procedure, of whom 46%
had a metabolic defect at baseline (47 had IGT and 19
had diabetes). In addition to the Lap-Band, all subjects
were directed to follow an intensive post-operative diet
(970 and 1090 kcal/d in women and men, respectively)
and exercise regimen (30 minutes aerobic exercise daily).
At one-year follow-up, 21% (30 out of 143 subjects)
were still reported to have either IGT or diabetes. Three-
year data revealed a persistent metabolic defect in 20%
of patients (n = 11/56). The investigators in this study
failed to present important data of patient weights, or
to look at IGT and diabetes as separate entities. Thus,
while inferred, the data is insufficient to clearly demon-
strate prevention or remission of type 2 diabetes with this
approach.
In another LASGB study, Dixon et al. [7] evaluated a
subset of 50 patients with type 2 diabetes, one year after
undergoing the Lap-Band procedure. Sixty-four percent
(n = 32) of patients who had previously been on oral
medication prior to surgery no longer required medication
and had normal fasting blood glucose, insulin, C-peptide,
and HbA1c . Twenty-six percent (n = 13) had significant
improvement in glycemia, including three out of four
insulin-treated patients who were able to reduce their
insulin doses. Only five patients in the oral medication
group failed to improve glycemic control.
Of the 434 obese individuals without diabetes from the
same study who underwent the LASGB procedure and
were followed for up to 4 years, none had developed
diabetes, and only 15% (n = 67) had developed IGT.
Of these, 57 were followed for at least 1 year, 30 were
followed for 2 years, 17 for 3 years, and 10 for 4 years.
Of those who were followed for at least two years, none
remained glucose intolerant. This data suggests that the
Lap-Band might also be a beneficial alternative in the
prevention of diabetes and its precursor, IGT, in high-risk
patients.
The authors concluded that improvement in glycemic
control was thought to be the result of enhanced
insulin sensitivity and B-cell function. Whereas insulin
sensitivity correlated with weight loss, improvement in
B-cell function was more closely related to the duration
of diabetes. This observation argues in favor of surgical
intervention earlier in the disease process while sufficient
B-cell function is present. In other studies, Pories et al. [5]
had also noted that ‘non-responders’ to bariatric surgery
had diabetes of longer duration, and Long et al. [6]
documented that early intervention in obesity can prevent
progression of IGT to type 2 diabetes.
These findings are further supported by a recently
published study by Polyzogopoulou et al. [8] who found
that after GBP, one of the defects in type 2 diabetes,
the loss of acute phase insulin response to glucose [35],
was resolved. The study followed 25 obese patients for
12 months after undergoing a biliopancreatic diversion
with Roux-en-Y gastric bypass. At baseline, 12 subjects
had type 2 diabetes, 5 had IGT, and 8 had normal glucose
Copyright  2004 John Wiley & Sons, Ltd.
C. V. Ferchak and L. F. Meneghini
tolerance by a 75-g oral glucose tolerance test according
to the American Diabetes Association (unrevised) criteria
[36]. The 8 NGT surgical subjects were similar in BMI to
the type 2 diabetes and IGT surgical subjects. Twelve non-
obese, normal glucose-tolerant subjects served as controls.
At baseline, insulin sensitivity was reduced in all three
obese surgical groups as compared with the controls
(p < 0.05). Acute insulin response (AIR) was essentially
absent in the diabetic group and reduced in the IGT
group. Furthermore, AIR in the IGT group was greatly
diminished for the degree of insulin resistance, whereas
AIR in the NGT group was greatly increased, appropriately
compensatory to the degree of insulin resistance.
All patients were studied at 12 months post-operatively.
BMI’s had decreased significantly and glycemic indices in
all surgical groups were significantly improved. There
was complete remission of type 2 diabetes in all cases. All
groups showed a reappearance of normal acute insulin
response. Insulin sensitivity had likewise returned to
normal in all groups, even though the patients were
still obese.
The maximum duration of disease in the type 2 diabetes
subjects was 3 to 5 years. The authors compared this to
a similar study [37] in which the defect of loss of AIR
was not restored with weight reduction. They posit that
this was due to study subjects with diabetes, which was
‘more severe. . . and of longer duration’ and that the loss
of glucose-induced AIR in obese patients with early or
moderately severe type 2 diabetes is reversible.
Improvement in insulin sensitivity and metabolic
control are the expected benefits of weight loss following
bariatric surgery. On the other hand the observations
that metabolic parameters improve dramatically within
days of gastric bypass, before any considerable weight
loss is achieved, raises some interesting questions about
the pathophysiology of the disease [38,39]. Although the
drastic reduction in caloric intake that follows bariatric
surgery, compounded by the nutrient malabsorption
induced by the gastric bypass, could possibly explain
some of the acute improvement in metabolic control,
the role of incretins and ‘anti-incretin factors’ affected
by the procedure may also be implicated [40]. Reports
from the bariatric literature have documented reductions
in Gastric Inhibitory Peptide (GIP) [41], leptin [38],
and ghrelin [42], as well as increases in Glucagon-Like
Peptide 1 (GLP-1) [43] following surgical intervention.
Adding to the hypothesis of an incretin effect, Rubino and
Marescaux [44] reported improved fasting plasma glucose
(159 ± 47 mg/dL vs 96.3 ± 10.1 mg/dL; p = 0.01) as
well as improved glucose tolerance with a greater than
40% reduction of the area under the blood glucose
concentration curve (P < 0.001) when they compared
bypass procedure in spontaneous non-obese rat models
of type 2 diabetes to sham-operated rats, given similar
caloric intake and having similar weight profile post-
operatively. Although more research is needed to better
define the role of the gut and its associated peptides in the
pathophysiology of insulin resistance and type 2 diabetes,
it appears clear that the benefits of gastric bypass in
Diabetes Metab Res Rev 2004; 20: 438–445.
Obesity, Bariatric Surgery and Type 2 Diabetes
individuals with type 2 diabetes are not limited to the
consequences of weight loss.
Conclusion
Given the observed progression of beta cell failure and
deteriorating glycemic control in most patients with
IGT or type 2 diabetes, the available data suggests an
effective and practical treatment option, which may offer
considerable improvement in glycemic control even in
patients with extreme insulin resistance. Moreover, these
studies and supporting data propose that any intervention,
whether surgical or non-surgical, for the treatment of
obesity-related type 2 diabetes has the most beneficial
effect early in the disease process before beta cell function
is substantially impaired and before the onset of chronic
complications [5–8].
We have attempted to contrast and summarize the
impact of 3 types of interventions (gastric bypass,
laparoscopic banding and intensive lifestyle regimen) on
the prevention and progression of type 2 diabetes, in the
obese patient (see Table 2).
Although more carefully conducted studies will be
needed to further clarify these preliminary findings, some
distinct trends may be seen in the current compilation of
data regarding the impact of bariatric surgery on glycemia.
The evidence suggests that all three interventions have a
positive impact on the prevention and progression of type
2 diabetes. Additionally, bariatric surgery has been shown
to achieve clinical remission, perhaps resolution, of type 2
diabetes in a substantial number of cases (Table 2: Impact
of Interventions on IGT and Type 2 Diabetes).
Short- and longer-term gastric bypass studies (median
follow up 2.3 to 9.6 years) have resulted in weight loss of
over 33% and BMI decreases of 30% from baseline. This
substantial and sustained amount of weight loss has been
associated with a 99 to 100% prevention of diabetes in
patients with IGT and an 80 to 90% clinical resolution
of diagnosed type 2 diabetes. Gastric banding results in
a lower median weight loss of 20%, a decrease in BMI
of 20%, and a 50 to 60% clinical remission of type 2
diabetes.
Overall, clinical studies have shown that about 40%
of persons who have purely restrictive procedures never
Table 2. Metabolic outcomes of Roux-en-Y, Lap-Band, and lifestyle interventions
Years of
Metabolic outcomes follow up Procedure
93% resolution of diabetes 3.5 years Roux-en-Y
93% resolution of diabetes 1 year Roux-en-Y
71% resolution of diabetes 9 years Roux-en-Y
64% resolution of diabetes 1 year Lap-Band
83% resolution of diabetes 7.6 years Roux-en-Y
99% non-progression
99% non-progressed 5.8 years Roux-en-Y
58% reduction in incidence 3.2 years Lifestyle intervention 265 patients with IGT
of diabetes
58% reduction in incidence 2.8 years Lifestyle intervention 1079 patients with IGT
of diabetes
Copyright  2004 John Wiley & Sons, Ltd.
443
achieve loss of more than half of their excess body weight
and in long-term studies, only about 30% of patients
have maintained persistent weight loss [46]. Finally, the
lifestyle intervention studies of obese and IGT patients,
(median follow up 3 years) achieve a 5 to 7% weight loss
with a 50% reduction in the progression to diabetes.
Of note is that outcomes from lifestyle intervention
were made possible within an experimental, subsidized
environment unlikely to be reproducible in the broader
clinical arena.
The impact of LASGB, as compared to gastric bypass, on
comorbidities such as diabetes is still unclear. A significant
problem in assessing this issue is the lack of specific data
regarding LASGB. Articles frequently cite improvement
of comorbidities and even resolution of diabetes [34,47],
but key details such as pre- and post-surgical weights,
as well as the specific numbers of patients improved
or in remission, are lacking, making much of the data
impossible to interpret.
It is difficult to compile and compare data among
studies lacking a standardized approach to defining and
collecting outcomes. The bariatric community is currently
trying to remedy this lack of standardization by creating
a national registry using common baseline and outcome
measurements for future studies [48].
Currently, data are presented using a variety of
measures. Baseline weight is sometimes described as
actual weight, excess weight (based on 1983 Metropolitan
Life Insurance idealized weight tables), or BMI. Changes
in weight are described as % change in BMI, % excess
weight loss, or actual weight loss. The measurements
of diabetes are similarly non-standardized. They may be
described by fasting blood glucose, random blood glucose,
an average of the two, HbA1c values, incidence of diabetes,
and relative reduction in incidence of diabetes. Future
studies would benefit from standardized baseline and
endpoint data (including patient demographics, duration
of diabetes, current types and doses of medication,
metabolic values, measures of insulin resistance and beta
cell function, and cardiovascular risk markers including
those associated with endothelial damage).
Another challenge to drawing meaningful conclusions
from the current data is the relatively short length of
follow up to the studies. The timeline of progression
Post-surgical weight
Baseline metabolic data change Reference
15 patients on diabetes medication 38% decrease in weight DeMaria [17]
13 patients with diabetes 34% decrease in weight Cowan [45]
49 patients on diabetes medication 33% decrease in weight MacDonald [29]
50 patients with diabetes 20% decrease in weight Dixon [7]
146 patients with diabetes 32% decrease in weight Poires [5]
152 with IGT
109 with IGT 52% excess weight loss Long [6]
5% decrease in weight Tuomilehto [26]
4.2% decrease in weight DPP [2]
Diabetes Metab Res Rev 2004; 20: 438–445.
444
from IGT to diabetes is not known. Thus, it becomes
problematic to state with certainty that a specific amount
of sustained weight reduction correlates to prevention of
the development of type 2 diabetes over an indefinite
length of time.
Many questions remain to be answered. Will prevention
or resolution of diabetes be sustained over time? When
controlling for weight loss, are Lap-Band and Gastric
Bypass similar in their effect on the pathophysiology
of insulin resistance and diabetes? Is the acute change
in metabolic status when bypassing the intestine
a result of changes in GI hormones, or is this
finding related to decreased caloric intake post-op? To
answer these and other questions, there is a need for
long-term, prospective, controlled clinical trials, which
focus greater attention on the endocrine aspects of
bariatric surgery and the pathophysiology of type 2
diabetes.
For those of us who are daily frustrated by the
failure of available strategies to help our patients control
type 2 diabetes and related complications, these studies
propose a treatment intervention that appears to be
effective, albeit, extreme. Given the higher risk of
both anesthetic and surgical complications in morbidly
obese patients, selection criteria for bariatric surgery
need to be carefully defined. Although the 1991 NIH
Consensus Report recommended only patients with ‘an
acceptable operative risk’, this presents a dilemma in
deciding who is a suitable candidate for surgery. The
heaviest patients with the most threatening medical
problems and the highest post-operative risk may be the
ones who need weight-loss surgery the most, because
they are at the greatest risk of further illness and
death.
Much experience is being gained in surgical
intervention for obesity. As techniques improve, so have
the mortality and morbidity rates when compared to the
almost certain prospect of lifetime, chronic ill health with-
out surgery [32]. Until the balance between lifestyle and
health can be restored, bariatric surgery is becoming a
viable treatment option for both obesity and type 2 dia-
betes. For many patients, once the benefits and risks have
been carefully considered, the option of bariatric inter-
vention, in centers with an experienced team of surgeons,
dieticians, and psychologists, may present the best oppor-
tunity for minimizing the long-term complications of the
disease.
Acknowledgments
We wish to thank Daniel H. Mintz, MD, Professor of Medicine,
Scientific Director Emeritus, of the Diabetes Research Institute
of the University of Miami School of Medicine for his always-
insightful critiques during preparation of this article. We also
wish to thank Andrew JM Boulton, MD, and Ronald Goldberg,
MD, of the Diabetes Research Institute, for their editorial
advice, and Thomas E. Woodward II for the bariatric surgery
diagrams
Copyright  2004 John Wiley & Sons, Ltd.
C. V. Ferchak and L. F. Meneghini
References
1. Eriksson J, Lindstrom J, Tuomilehto J. Potential for the
prevention of type 2 diabetes. Br Med Bull 2001; 60: 183–199.
2. Diabetes Prevention Program Research Group: Reduction in
the incidence of type 2 diabetes with lifestyle intervention or
metformin. N Engl J Med 2002; 346: 393–403.
3. UK Prospective Diabetes Study Group: Intensive blood-
glucose control with sulphonylureas or insulin compared with
conventional treatment and risk of complications in patients
with type 2 diabetes. Lancet 1998; 352: 837–853.
4. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thomp-
son TJ, Venkat Narayan KM. A diabetes report card for the
United States: quality of care in the 1990s. Ann Intern Med
2002; 136: 565–574.
5. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have
thought it? An operation proves to be the most effective therapy
for adult onset diabetes mellitus. Ann Surg 1995; 222(3):
339–350; Discussion 350–352.
6. Long S, O’Brien K, MacDonald KG Jr, et al. Weight loss in
severely obese subjects prevents progression of impaired glucose
tolerance to type II diabetes. Diabetes Care 1994; 17: 372–375.
7. Dixon JB, O’Brien PE. Health outcomes of severely obese type
2 diabetic subjects 1 year after laparoscopic adjustable gastric
banding. Diabetes Care 2002; 25: 358–363.
8. Polyzogopoulou EV, Kalfarentzos F, Vagenakis AG. Restoration
of euglycemia and normal acute insulin response to glucose in
obese subjects with type 2 diabetes following Bariatric surgery.
Diabetes 2003; 52: 1098–1103.
9. Albrecht RJ, Pories WJ. Surgical intervention for the severely
obese. Clin Endocrinol Metab 1999; 13(1): 149–172.
10. Leibbrand R, Fichter MM. Maintenance of weight loss after
obesity treatment: is continuous support necessary?. Behav Res
Ther 2002; 40(11): 1275–1289.
11. NIH conference: Gastrointestinal surgery for severe obesity.
Consensus development conference panel. Ann Intern Med 1991;
115: 956–961.
12. Foster GD, Wadden TA, Vogt RA, Brewer G. What is a
reasonable weight loss? Patient’s expectations and evaluations
of obesity treatment outcomes. J Consult Clin Psychol 1997; 65:
79–85.
13. Kremen AJ, Linner JH, Nelson CH. An experimental evaluation
of the nutritional importance of proximal and distal small
intestine. Ann Surg 1954; 140: 439–448.
14. Kral JG, Gortz L, Hermansson G, et al. Gastroplasty for obesity:
long-term weight loss improved by vagotomy. World J Surg
1993; 17(1): 75–78.
15. Garrow JS, Gardiner GT. Maintenance of weight loss in obese
patients after jaw wiring. BMJ (Clin Res Ed) 1981; 282: 858.
16. FDA New Device Approvals. Available from http://www.fda.gov
/cdrh/mda/docs/p000008.pdf. Accessed 30 March 2003.
17. DeMaria EJ, Sugerman HJ, Kellum JL, et al. Results of 281
consecutive total laparoscopic Roux-en-Y gastric bypasses to
treat morbid obesity. Ann Surg 2002; 235(5): 640–647.
18. Wittgrove AC, Clark GW. Laproscopic gastric bypass, Roux en-Y.
500 patients: technique and results, with 3–60 month follow-up.
Obes Surg 2000; 10: 233–239.
19. Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric
bypass: technique and 3-year follow-up. J Laparoendosc Adv
Surg Tech 2001; 11(6): 377–382.
20. Schauer PR, Sayeed K, Gourash W, et al. Outcomes after
laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann
Surg 2000; 232(4): 515–529.
21. Choban Smith P, Jackson B, Poplawski S, et al. Bariatric surgery
for morbid obesity: why, who, when, how, hwere, and then
what? Cleve Clin J Med 2002; 69(11): 897–903.
22. Byrne TK. Complications of surgery for obesity. Surg Clin North
Am 2001; 81: 1181–1193.
23. Zinzindohoue F, Chevallier JM, Douard R, et al. Laparoscopic
gastric banding: a minimally invasive surgical treatment for
morbid obesity: prospective study of 500 consecutive patients.
Ann Surg 2003; 237(1): 1–9.
24. Ceelen W, Walder J, Cardon A, et al. Surgical treatment of
severe obesity with a low-pressure adjustable gastric band:
experimental data and clinical results in 625 patients. Ann Surg
2003; 237(1): 10–16.
Diabetes Metab Res Rev 2004; 20: 438–445.
Obesity, Bariatric Surgery and Type 2 Diabetes
25. Sherwin RS, Anderson RM, Buse JB, et al. ADA Position
Statement: The prevention or delay of type 2 diabetes. Diabetes
Care 2002; 25(4): 742–749.
26. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type
2 diabetes mellitus by changes in lifestyle among subjects
with impaired glucose tolerance. N Engl J Med 2001; 344(18):
1343–1350.
27. Chiasson JL, Gomis R, Hanefeld M, Josse RG, Karasik A,
Laakso M. The STOP-NIDDM trial: an international study on
the efficacy of an alpha-glucosidase inhibitor to prevent type
2 diabetes in a population with impaired glucose tolerance:
rationale, design, and preliminary screening data: study to
prevent non-insulin-dependent diabetes mellitus. Diabetes Care
1998; 21: 1720–1725.
28. Buchanan TA, Xiang AH, Peters RK, et al. Preservation of
pancreatic b-cell function and prevention of type 2 diabetes
by pharmacological treatment of insulin–resistance in high-risk
Hispanic women. Diabetes 2002; 51: 2796–2803.
29. MacDonald KG, Jr, Long SD, Swanson MS, et al. The gastric
bypass operation reduces the progression and mortality of non-
insulin-dependent diabetes Mellitus. Gastrointest Surg 1997;
1(3): 213–220.
30. ASBS Rationale for The Surgical Treatment Of Morbid Obesity.
Available from http//: www.asbs.org/html/ration.html.
Accessed 30 March 2003.
31. Sullivan M, Karlsson J, Sjostrom L, et al. Swedish obese subjects
(SOS)-an intervention study of obesity. Baseline evaluation of
health and psychosocial functioning in the first 1743 subjects
examined. I J Obe Relat Metab Disord 1993; 17(9): 503–512.
32. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reduction in
incidence of diabetes, hypertension and lipid disturbances after
intentional weight loss-induced by bariatric surgery. Obes Res
1999; 7(5): 477–484.
33. Sjostrom CD, Peltonen M, Wedel H, Sjostrom L. Differentiated
long-term effects of intentional weight loss on diabetes and
hypertension. Hypertension 2000; 36(1): 20–25.
34. Pontiroli AE, Pierluigi P, Liberenti MC, et al. Laparoscopic
adjustable gastric banding treatment of morbid (grade 3) obesity
and its metabolic complications: a three-year study. J Clin
Endocrinol Metab 2002; 87(8): 3555–3561.
35. Del Prato S, Marchetti P, Bonadonna RC. Phasic insulin release
and metabolic regulation in type 2 diabetes. Diabetes 2002; 51:
S109–S116.
Copyright  2004 John Wiley & Sons, Ltd.
445
36. Report of the expert committee on the diagnosis and
classification of diabetes mellitus. Diabetes Care 1997; 20:
1183–1197.
37. Hughes TA, Gwynn JT, Switzer BR, et al. Effects of caloric
restiction and wight loss on glycemic control, insulin release
and resistance, and atherosclerotic risk in obese patients with
type 2 diabetes mellitus. Am J Med 1984; 77: 7–17.
38. Hickey MS, Pories WJ, MacDonald KG, et al. A new paradigm
for type 2 diabetes mellitus: could it be a disease of the foregut?.
Ann Surg 1998; 227(5): 637–644.
39. Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic
diversion. World J Surg 1998; 22: 936–946.
40. Rubino F, Gagner M. Potential of surgery for curing type 2
diabetes mellitus. Ann Surg 2002; 236(5): 554–559.
41. Clements RH, Gonzalez QH, Long CI, Wittert G, Laws HL.
Hormonal changes after Roux-en Y gastric bypass for morbid
obesity and the control of type-II diabetes mellitus. Ann Surg
2004; 70(1): 1–4; discussion 4–5.
42. Tritos NA, Mun E, Bertkau A, Grayson R, Maratos-Flier E,
Goldfine A. Serum ghrelin levels in response to glucose load
in obese subjects post-gastric bypass surgery. Obes Res 2003;
11(8): 919–924.
43. Naslund E, Backman L, Holst JJ, Theodorsson E, Hellstrom PM.
Importance of small bowel peptides for the improved glucose
metabolism 20 years after jejunoileal bypass for obesity. Obes
Surg 1998; 8(3): 253–260.
44. Rubino F, Marescaux J. Effect of duodenal-jejunal exclusion in
a non-obese animal model of type 2 diabetes: a new perspective
for an old disease. Ann Surg 2004; 239(1): 239–249.
45. Cowan GS, Buffington CK. Significant changes in blood pressure,
glucose, and lipids with gastric bypass surgery. World J. Surg
1998; 22: 987–992.
46. DeMaria EJ, Sugerman HJ. A critical look at laparoscopic
adjustable silicone gastric banding for surgical treatment of
morbid obesity. Does it measure up? Surg Endosc 2000; 14:
697–699.
47. Rubenstein R. Laparoscopic adjustable gastric banding at a U.S.
center with up to 3-year follow-up. Obes Surg 2002; 12(3):
380–384.
48. NIDDK Working Group on Bariatric Surgery: Executive Summary
2002; Available from http://www.niddk.nih.gov/fund/crfo/
Bariatric-Surgery-final.pdf. Accessed 30 March 2003.
Diabetes Metab Res Rev 2004; 20: 438–445.