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OPINION


‘cutting out’ the cost of type 2 diabetes


WIth tYPE 2 dIaBEtES noW affEctIng SIx PEr cEnt of thE PoPUlatIon (and rISIng) and coStIng tEn PEr cEnt of thE hEalth BUdgEt (£400M), tErrY MagUIrE conSIdErS hoW BarIatrIc SUrgErY MaY EVEntUallY SaVE oUr hEalth SErVIcE BUt aSkS, do WE haVE thE aPPEtItE for It?


By Terry Maguire t


he northern Ireland audit office (nIao) report ‘type 2 diabetes; prevention and care’,


which was published in March, is critical of the department of health’s (doh’s) failures in both creating and implementing policy for type 2 diabetes.


Its cause is mainly lifestyle, with obesity accounting for about 80 per cent of all new cases, yet this makes it eminently preventable, with a 60 per cent 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 ten per cent through healthy eating and moderate exercise. oh, and it’s curable, if action is taken early enough. With a 70 per cent increase in the last fifteen years, the nIao is right to point out that, 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 our collective 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.


22 - PharMacY In focUS


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.


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 per cent 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 per cent of excess weight for vertical-banded gastroplasty and a 72 per cent mean loss for gastric bypass surgery.


there will always be a trade-off between the risks of surgery and the consequences of life-long 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 gives a 50-60 per cent of excess body weight during the first twelve to 24 months, meaning that a person weighing 300lb loses 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, have demonstrated more than a 75-90 per cent resolution rate of type 2 diabetes; a 66 per cent resolution for hypertension, as well as 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 considered that, if northern Ireland complied with the nIcE guidance on bariatric surgery, then some 50,000 local residents would be eligible for the cut. It is likely that perhaps only three per cent of this group would be brave enough to consider it, but 1,500 is better than the pathetically low 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 costs £1.5 million.


In an ideal world we would all heed the call to eat a better diet and take more exercise, but there seems to be little appetite for this. therefore it’s perfectly reasonable to suggest that we invest £20 million in gastric surgery for the obese and do this as a means of managing, preventing and ‘curing’ type 2 diabetes. this offers much better value for money than the current failing approach which has the potential to eventually bankrupt our health service.


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