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Type 2 diabetes mellitus (T2DM) is a critical health problem in the United States and other developed countries that have a high prevalence rate and a significant number of risk factors. Apart from the conventional therapy involving lifestyle changes and pharmacological treatment, bariatric surgery is also used to treat T2DM in obese patients. Evidence-based practice relies on three main terms: research evidence, patient preference, and past clinical experience (Melnyk & Fineout-Overholt, 2015).
Therefore, before deciding whether or not bariatric surgery should be used for diabetes management, it is critical to evaluate the evidence in support of it and define the key considerations. The present paper will examine how bariatric surgery could fit into the evidence-based practice of T2DM management by outlining its effectiveness and the risks associated with it.
Standard Treatment of Type 2 Diabetes
Type 2 diabetes is greatly influenced by lifestyle factors, including nutrition and smoking, as well as the patients weight. Obesity remains among the main risk factors for T2DM, which also include genetic predisposition and poor diet. Thus, the ADA (2015) states that patient education, healthy lifestyle, smoking cessation, and psychosocial care are at the foundation of T2DM prevention and management.
These interventions help to decrease patients body fat and blood pressure, as well as control their blood sugar levels. Apart from the treatment mentioned above, patients might also need psychological help to avoid depression, eating disorders, and diabetes distress (ADA, 2015). As many long-term disorders, diabetes can influence patients quality of life, leading to undesirable psychological effects. It is recommended that health providers check diabetic patients for symptoms of mental disorders and refer them to specialists, if necessary.
Apart from lifestyle and psychological interventions, standard care for T2DM also involves pharmacological therapy. ADA (2015) recommends pharmacological treatment with metformin as a first-line option for managing the condition.
Nevertheless, research shows that pharmacological treatment of diabetes has significant limitations. As demonstrated by Schauer et al. (2014), only 5% of obese women ages 40-56 achieved an improvement in their quality of life after three years of intensive pharmacological treatment. Hence, while the standard method is considered to be the safest and the most cost-efficient alternative, it is not always effective in lowering patients body mass and improving their quality of life.
Bariatric Surgery in Diabetes Management
Effectiveness
Bariatric surgery is a complex of surgical procedures aimed at diminishing the size of a patients stomach, thus reducing patients body fat and overall weight. As mentioned above, one of the main factors that lead to type 2 diabetes is obesity. However, losing weight may be a challenge for many people, particularly those with physically underactive jobs and psychological problems. Bariatric surgery can help people with such conditions to lose weight and, therefore, increase the chance of complete remission of T2DM.
ADA (2015) states that bariatric surgery may be considered for a particular group of patients with T2DM, especially if diabetes or associated comorbidities are difficult to control with lifestyle and pharmacological therapy (p. 104). Thus, it is essential to review the evidence in support of this treatment methods and to evaluate some of the considerations and risks associated with bariatric surgery.
As bariatric surgery is among the most popular methods of obesity management, there is plenty of research reviewing its effectiveness in various patient populations. For instance, Brethauer et al. (2013) mention that patients who underwent gastric bypass surgery, which is a type of bariatric surgery, lost an average of 52 kg/m2 to 40 kg/m2 of weight. The researchers also considered the effect of the surgery on diabetes management.
The study found that 99% of patients with type 2 diabetes mellitus who underwent a gastric bypass surgery experienced complete remission (52%), partial remission (19%) or an improvement (28%) in the short term (Brethauer et al., 2013). The long-term results of the procedure were also impressive, showing that 96% of patients maintained one of the results mentioned above three years after the surgery (Brethauer et al., 2013). Therefore, evidence shows that gastric bypass surgery has a positive effect on patients with obesity who were also diagnosed with T2DM.
Negative Effects and Limitations
While being a very effective way of treating type 2 diabetes, bariatric surgery has some negative factors that patients and care providers must consider. The Swedish Obese Subject Study in 2010 showed an alarmingly high T2DM recurrence rate of 50% in the surgery group (Brethauer et al., 2013). The reason for that may be the fact that easy-to-reach results often prove to be unstable, while the results achieved through hard work seem to linger longer.
Even though such a recurrence rate may be considered a failure, there remained significant reductions in macrovascular events and mortality in the surgery group in comparison with the standard treatment group (Brethauer et al., 2013). The other negative factor is facing overall surgery risks, such as pain, tachycardia, wound infection, nutritional deficiencies, and bleeding. While those risks are common, the study by Schauer et al. (2014) shows little long-term side effects in the bariatric surgery group among women. Hence, if the patient does not have an increased risk of adverse events as a result of a surgery, bariatric surgery can be considered as one of the options.
Besides everything mentioned above, there are also certain limitations to recommending bariatric surgery, particularly in terms of patients weight. Although several trials have shown positive results in patients with T2DM and body mass index from 30 kg/m2 to 35 kg/m2, there is currently not enough evidence to recommend surgery in patients with BMI less than 35 kg/m2 (ADA, 2015). In short, although bariatric surgery is quite an effective way of treating type 2 diabetes mellitus, it cannot be considered as a universal cure for this condition and should not be used for all patients with T2DM.
Bariatric Surgery in Evidence-Based Practice for Diabetes Management
On the whole, there is sufficient evidence to suggest that bariatric surgery should be included in evidence-based practice for the management of T2DM. Bariatric surgery can be more effective than diet and exercise in achieving long-term weight loss, thus addressing one of the critical factors affecting the development and persistence of T2DM. However, in considering bariatric surgery for patients with diabetes, care providers should also consider patient information and their preferences. While bariatric surgery may be a practical solution, it poses significant risks for the patient. Therefore, care providers should explain all the information regarding this method to the patient and rely on patients choice in their evidence-based practice.
Lastly, as the procedure is not common in diabetes management, it is also critical for care providers to reflect on their past experiences with this method when deciding whether or not it should be used for treating a patient. Performing all of the above steps would help healthcare professionals to adhere to evidence-based practice norms while also ensuring that the chosen treatment method would be the most appropriate for a particular patient.
Conclusion
Although bariatric surgery has a variety of risks and limitations, bariatric surgery is associated with positive long-term patient outcomes and could be more effective than standard therapy in increasing the probability of remission of diabetes. Thus, bariatric surgery can be successfully used for type 2 diabetes management. However, in considering this method, care providers must adhere to the principles of evidence-based practice and refer to research evidence, patient preferences, and previous clinical experience before making a conclusion.
References
American Diabetes Association (2015). Standards of medical care in diabetes2015 abridged for primary care providers. Clinical Diabetes, 33(2), 97111.
Brethauer, S. A., Aminian, A., Romero-Talamás, H., Batayyah, E., Mackey, J., Kennedy, L., &Schauer, P. R. (2013). Can diabetes be surgically cured? Annals of Surgery, 258(4), 628637.
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Schauer, P. R., Bhatt D. L., Kirwan J. P., Wolski, K., Stacy A., Brethauer, S. A., & Kashyap, S. R. (2014). Bariatric surgery versus intensive medical therapy for diabetes 3-year outcomes. The New England Journal of Medicine, 370(21), 2002-2013.
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