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DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009. ADA Guidelines 2009: Bariatric Surgery. ● Bariatric surgery should be considered for adults with BMI > 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. (B)

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DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

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  1. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  2. ADA Guidelines 2009: Bariatric Surgery ● Bariatric surgery should be considered for adults with BMI > 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. (B) ● Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and medical monitoring. (E) • Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI of 30–35kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI 35 kg/m2 outside of a research protocol. (E) ● The long-term benefits, cost effectiveness, and risks of bariatric surgery in individuals with type 2 diabetes should be studied in well-designed randomized controlled trials with optimal medical and lifestyle therapy as the comparator. (E) DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  3. ADA Guidelines 2009: Bariatric Surgery Gastric reduction surgery, either gastric banding or procedures that involve bypassing or transposing sections of the small intestine, when part of a comprehensive team approach, can be an effective weight loss treatment for severe obesity, and national guidelines support its consideration for people with type 2 diabetes who have BMI at or exceeding 35kg/m2. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  4. ADA Guidelines 2009: Bariatric Surgery Bariatric surgery has been shown to lead to near or complete normalization of glycemia in 55–95% of patients with type 2 diabetes, depending on the surgical procedure. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  5. ADA Guidelines 2009: Bariatric Surgery …. there is increasing evidence that intestinal bypass procedures may have glycemic effects that are independent of, and additive to, their effects on weight. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  6. ADA Guidelines 2009: Bariatric Surgery Rates of morbidity and mortality directly related to the surgery have been reduced considerably in recent years, with 30-day mortality rates now 0.28%, similar to those of laparoscopic cholecystectomy. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  7. ADA Guidelines 2009: Bariatric Surgery Cohort studies attempting to match subjects suggest that the procedure may reduce longer-term mortality rates, and it is reasonable to postulate that there may be recouping of costs over the long run. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  8. HbA1c7% HbA1c7% HbA1c7% Yes No Yes No Yes No HbA1c7% HbA1c7% No Yes No Yes ADA/EASD Consensus Algorithm for Type 2 DM* Diagnosis Nathan D, et al. Diabetologia 2006;49:1711−21. Lifestyle Intervention and Metformin HbA1c7% Yes No Add Basal Insulin − (most effective) Add Sulfonylurea − (least expensive) Add GLitazone −( no hypoglycemia) Intensify Insulin Add Glitazone Add Basal Insulin Add Sulfonylurea Add Basal or intensify insulin Intensive insulin + metformin ± glitazone • Check HbA1c every 3 months and act until HbA1c is <7% • Although 3 oral agents can be used, insulin therapy is preferred based on effectiveness and expense * If BMI > 35 Bariatric Surgery should be considered (2009 ADA Guidelines)

  9. Consensus: Diabetes Surgery SummitRome, Italy, March 29-31, 2007 Bariatric surgery is recommended for patients with Type 2 diabetes and severe obesity (BMI >35). Bariatric surgery may be an option (as non-primary RX) for patients with Type 2 diabetes and severe obesity (BMI 30-35).

  10. ADA Guidelines 2009: Bariatric Surgery ● Bariatric surgery should be considered for adults with BMI > 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. (B) • Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI of 30–35kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI 35 kg/m2 outside of a research protocol. (E) DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

  11. The Tide is TurningFuture Emphasis: • Enhanced Dialogue with Diabetologists • Dialogue with Physicians • Level 1 Clinical Trials

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