Diabetes & Bariatric Surgery: A Guide for Patients

Article By: Rachel Ignomirello, MS, RDN, CSOWM, LDN

Rachel Ignomirello is a Bariatric Dietitian and Board-Certified Specialist in Obesity and Weight Management.

The disease of obesity is chronic and affects around 42% of all US adults. Obesity-related conditions include heart disease, stroke, certain types of cancer, and type 2 diabetes. In fact, the risk of developing diabetes is 10 times higher in people with obesity. In today’s blog, I will discuss diabetes and the impact of bariatric surgery.

1) What is diabetes and why should I care? Diabetes is a chronic disease that occurs when blood sugar (“blood glucose”) is too high. Blood glucose is the body’s preferred energy source, and it comes from carbohydrates. Normally, the body uses insulin, a hormone from the pancreas, to unlock cells and let glucose in to use it as energy. With diabetes, the body either doesn't produce enough insulin or it does not use the insulin well. This causes a build-up of glucose (hyperglycemia) in the blood. For people with type 1 diabetes, the body does not make insulin. For people with type 2 diabetes, the body does not make enough insulin or does not use it well. Type 2 is the most common type of diabetes and the one I will be focusing on.

People are more likely to develop type 2 diabetes if they are 45 or older, are overweight, and/or have a family history of diabetes. The risk of developing diabetes increases with the number of affected family members. Genetics plays a role in diabetes, however, lifestyle choices (eating and physical activity behaviors) can also make a big difference. Diabetes is a costly disease to both wallet and body. According to the American Diabetes Association, all types of diagnosed diabetes in the US cost $327 billion in 2017. The expense happens because uncontrolled diabetes can lead to heart disease (heart attack and stroke), kidney disease (kidney failure and dialysis), nerve damage (neuropathy and amputation), and eye disorders (blindness). Diabetes is one of the top 10 leading causes of death in the United States. Diabetes can be managed with improved lifestyle choices and medications, but many people may not realize how powerful bariatric surgery can be.

2) Bariatric surgery for diabetes. Once regarded as only a weight loss procedure, decades of research now supports bariatric surgery (or “metabolic surgery”) as an effective treatment for type 2 diabetes. For most, it results in blood glucose improvement and even remission. Bariatric surgery shrinks the gastrointestinal track and reduces portions, but it also changes metabolism in intestinal hormones that regulate blood sugar. With decreased hunger and increased fullness, patients now have a tool to achieve a healthy weight.

The improvements in blood sugar happen within days after surgery. So much so that people are often able to immediately reduce or stop diabetes medications [with the help of their provider]. 60-80% of bariatric patients with type 2 diabetes will experience improvements in diabetes within the first year following surgery. In the first five years, over 80% of patients achieve diabetes remission. Remission is defined as A1c less than 6.5% after 3 months without diabetes medication. Relapse does happen, more so with the sleeve gastrectomy surgery type compared to gastric bypass. Therefore, healthy lifestyle choices are imperative long-term — not only for weight management but also for diabetes management.

3) Are there any considerations for bariatric patients with diabetes? Postoperative bariatric patients lose weight in the short-term because of the pouch restriction and metabolic changes. Over the long-term, weight loss maintenance can boil down to following the bariatric basics of what, when, and how much to eat. Typically, a bariatric diet is high-protein, low-carb (sugar), and low-fat. If patients start to over-consume carbohydrates, they may experience an increase in weight and blood glucose.

A possible risk of bariatric surgery is called “reactive hypoglycemia.” This risk is a result of low blood sugar within 2-4 hours of eating. Signs and symptoms may include dizziness, shakiness, confusion, cold sweats, or hunger. If symptoms are mild and it is time for the next meal, it can be as simple as eating a balanced meal or snack. Balance means including both a protein source and a healthy carbohydrate source to stabilize the blood sugar. Examples include apple with peanut butter, Greek yogurt, cheese with crackers, or half a deli meat sandwich. The biggest mistake patients make is what I call “naked carbs,” where they consume carbohydrates as a meal or snack without any protein. What goes up will come down. If symptoms become serious, blood sugar must be raised quickly with a small amount of pure sugar (glucose tablets, glucose gel, juice, etc.) often followed by a balanced meal or snack. Prevention is key, though. Patients should avoid skipping meals and limit/avoid concentrated sweets. If reactive hypoglycemia happens frequently, it is time to see the bariatric team for a diet assessment.

BariMelts provides general recommendations, not to be construed as medical advice. Please consult your doctor.

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