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Banded, Stapled, Saved

New research shows that weight-loss surgery can reduce the risk of type 2 diabetes by close to 80 percent. With more than two-thirds of Americans overweight or obese, that’s no small matter.

Quitting smoking, the old saw goes, is easy to do—I’ve done it dozens of times. It’s staying clean that poses the real challenge. So, too, with losing weight: despite the pills, pedometers, hypnosis, and low-cal breakfast bars, pounds have a way of creeping back onto the hips. More than a third of Americans are now overweight, and another third obese, according to the Centers for Disease Control and Prevention, with black and Hispanic women hit hardest. Among children, one in 10 pre-kindergarten students are obese; in elementary schools, that figure is one in five.

Neither our bodies nor our healthcare system is designed to bear this load. Obesity leads to heart disease, strokes, certain cancers, perhaps even Alzheimer’s. It also causes insulin resistance, which limits the body’s ability to control blood sugar and, left untreated, leads to diabetes. Some 26 million Americans are now diabetic—including more than a quarter of senior citizens—and living with complications of the disease, including kidney failure, blindness, and lower-limb amputation. The CDC reports (pdf) that diabetics are at double the risk of death than their healthy peers, and face twice the hospital bills. An estimated 80 million Americans are thought to be “pre-diabetic,” too—an ominous number, and one that will only climb.

A recent study in the New England Journal of Medicine examined how bariatric—i.e. weight-loss—surgery might prevent the onset of type 2 diabetes among at-risk adults, and the results were dramatic: obese subjects who had their stomachs stapled or banded were 78 percent less likely to later develop diabetes than their untreated peers. And the highest-risk patients, those with worrisome blood glucose levels at the outset of the study, did even better: bariatric surgery reduced their chance of diabetes by 87 percent. The findings suggest that, for those who can afford it, surgery may be a last, best attempt to prevent a dangerous disease.

In the study, Swedish researchers followed 4,000 obese middle-aged subjects—all of whom were at risk of diabetes but did not yet have the disease—for up to 15 years. Half of the patients underwent surgical interventions, ranging from “banding,” a relatively non-invasive procedure in which a saline-filled band reduces functional stomach size, to “gastric bypass,” in which the digestive tract is rerouted around part of the lower intestine. Those who opted against surgery were offered only what counseling was available through their primary care doctors, such as advice about eating right and the importance of exercise.

Differences between the two approaches began to show almost immediately. After one year, subjects in the surgery group had lost an average of 68 pounds each; average weight loss in the counseling-only group, meanwhile, never exceeded six pounds, and many patients even gained weight. By the end of the study, the surgery group had regained a few pounds, but still realized an average loss of 44 pounds.

When researchers crunched the data, they discovered just how well surgery worked: for every 13 bariatric patients in the cohort, 10 were now living diabetes-free. (Plus, at the outset of the study, the surgery group weighed 13 pounds more and had higher risk factors than the control group.) Such a dramatic risk reduction, the authors wrote, was more than twice as large as had ever been demonstrated in previous behavior-modification studies.

Which raises an interesting question: at what point is stomach surgery not just a viable option but the correct one? Dr. Danny Jacobs, a surgeon at Duke University, called the Swedish study’s findings “provocative and exciting” in an editorial that accompanied the research, but added, “It remains impractical and unjustified to contemplate the performance of bariatric surgery in the millions of eligible obese adults.” Diabetes is a disease with many causes, not all of them understood or weight-related. And bariatric surgery has only become a commonly performed procedure in recent decades, from less than 20,000 operations in the early 1990s to 220,000 in 2008; its long-term efficacy is unproven. (It can also be prohibitively expensive, with a price tag of $15,000 to $30,000, plus additional costs for post-operative cosmetic surgery.)

Less invasive procedures are always preferable, Jacobs argued, and indeed, many pre-diabetic Americans ought to be able to control their weight—and by extension their blood sugar levels—through diet and exercise alone. But as the Swedish study demonstrates, the current approach to helping patients lose weight, sans surgery, is severely lacking; public health officials will need a major breakthrough in behavioral psychology or pharmacology before anything works so well as stapling Americans’ stomachs shut.

Somehow, it’s always easier to shed those pounds than to keep them from coming back.