The prognosis for people who develop type 2 diabetes in childhood is generally poor, and the treatment options limited, compared with adults.
Metabolic surgery is highly effective in adults, but is a major procedure often regarded as a last resort for the severely obese. However, unlike most other treatments it has the potential to send type 2 diabetes into remission, which in children could mean sparing them from many decades of living with the disease and its complications.
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Torsten Olbers (Linköping University, Sweden) notes that there is a shift taking place in how gastric surgery is viewed, certainly for adults and beginning to trickle down to adolescents. Formerly it was a last resort for treating severe obesity, with the known metabolic benefits an added bonus. “Now,” he says, “you have a switch, or a swap, in the indication, so you can say that the best treatment for type 2 diabetes is a bariatric procedure and, by the way, you will also lose weight.”
Convincing data
There is a wealth of solid data in adults supporting bariatric surgery, particularly Roux-en-Y gastric bypass, for triggering weight loss that is not regained – or not completely regained; Olbers puts the odds of this at 90–95%, with a large degree of individual variability.
“The general group will lose around 15 points of BMI and they will regain maybe 10% to 20% of that weight loss over time,” he says, although he concedes: “If you are very big, you will not become normal weight.”
And a small proportion do regain all of their weight. “Then you have to think, of course, where would I be if I didn’t have the surgery, just to try to soften their feeling of defeat in this,” says Olbers. He stresses that the average BMI of the nonsurgical control groups in the bariatric surgery studies increases by around 10% in 5 years, on average.
However, “if you take type 2 diabetes, I think the jury’s still out,” he says.
Unlike in adults, there have not yet been studies specifically of metabolic surgery in children; all conclusions are based on children undergoing surgery for weight loss who also happened to have type 2 diabetes, and are therefore less definitive.
But the results to date are promising. Olbers cites his team’s first study of 80 children undergoing bariatric surgery, including 13 with prediabetes and three with type 2 diabetes, all of whom were free of these conditions at the 5-year follow-up.
And recent data from the US Teen-LABS study showed that, among children who had been obese since their teenage years, the rates of type 2 diabetes remission were markedly higher for those who underwent bariatric surgery between the ages of 13 and 19 years than among those who delayed it until the age of 25 years or older.
So despite the variable effect of surgery on weight per se, Olbers suggests that metabolic surgery for type 2 diabetes in adolescents “might be the sweet spot where you can make a tremendous impact on their health, over decades to come.”
Life after surgery
Compared with dieting or taking a pill, the decision to undergo metabolic surgery is daunting, especially if candidates for the procedure lack a clear idea of what awaits them on the other side.
Olbers stresses how important it is “to have the networks and the patient support groups and letting [candidates for surgery] meet other young people who have had surgery and see the good things, but also seeing the risk of complications.”
Most people, he says, live a very normal life after an initial period of adjustment, and report that in a normal day or week, they do not think about their operation and its aftereffects. This is an important point to stress not just to candidates for surgery, says Olbers, but also to other healthcare professionals, who tend to encounter and be aware of the people who have had complications arising from surgery and struggle with eating afterwards, rather than those for whom it went well.
He says for the majority of people, “you have a first period of some weeks, up to some months, when you have to adapt to your new signals, you have to adapt to a new way of eating. They now feel that they feel better when they eat a salad, compared to eating French fries, which is a usual phenomenon, or they need to eat a bit slower compared to eating very fast.”
But experience suggests that adolescents, being less set in their ways than older surgical patients, can adapt more easily, he notes.
Olbers mentions the phenomenon of “dumping,” where undigested food gets dumped directly from the stomach pouch into the small intestine.
“[Dumping] is quite often brought forward as some kind of complication because it is when you eat very fast, or eat too much sweet food or fatty food,” he says.
“You get side effects. The most common is you get tired, you have to lie down but you can also get palpitations and you can get pain and you can feel very distressed by this phenomenon. You forget that you have had the operation and you eat a big ice-cream in the summertime. You get a huge dump so you have to leave your friends and you have to lie down for a while.”
However, his team has studied the phenomenon and, perhaps somewhat counterintuitively, found that most patients view it as a positive factor, because its existence helps them stick to a healthy eating plan.
Complications and caveats
The overall contemporary complication rate for bariatric surgery is around 7–8%, says Olbers, and 2–3% for more substantial complications, with the rates for adolescents generally “in the lower range of that.”
There is no record of anyone dying after bariatric surgery in adolescence, he says, and there is a range of complications such as bowel obstruction and gallstones that were formerly common but are now extremely rare.
When performed in children, there is no evidence that bariatric surgery has a negative impact on growth. However, patients will need to take multivitamins for the rest of their lives following surgery, which may be particularly unpopular with younger people: “You don’t want to have those pill boxes when you are a teenager,” says Olbers.
And in the longer term, he notes that bone health is also a concern, with the potential for an increased risk for fracture.
Another important issue is that children with severe obesity are more likely than those in the general population to have mental health disorders. And although surgery may improve some of these, especially those directly related to food, there are many others that will require ongoing psychosocial care.
But Olbers believes that children undergoing metabolic surgery for type 2 diabetes will be in a better position to receive all the necessary associated and follow-up care than those undergoing bariatric surgery for obesity.
“You have the structures, the structures in the healthcare for diabetes, but you don’t have any kind of firm structures for obesity care in the same way,” he observes.
“People don’t understand that obesity is a disease, [so] okay, you have this operation and then you have to be on your own. But if you have a condition like diabetes, you understand that this is a chronic lifelong disease and you need other types of care besides just the operation.”
Recognizing the window of opportunity
Although the concept of type 2 diabetes as a reversible condition is itself relatively recent, most data suggest that “the earlier you can treat your diabetes, the better the results,” Olbers observes.
“You have 1 or 2 golden years when you can actually achieve almost lifelong remission of your diabetes, while if you have it for 5 or 10 years, you will have maybe a 75% chance of getting out of your treatment.”
This adds a sense of urgency when considering the few treatment options available to a teenager with obesity and type 2 diabetes – currently just lifestyle modifications; metformin, insulin, and liraglutide; and surgery.
But Olbers concedes that the thought of surgery – the “S word” as he puts it – is off-putting for many teenagers and their families, and prefers to position it simply as “one of the things in the toolbox.”
And for all the proven benefits of surgery, he points out that “if you had a very bumpy journey after your surgery and you didn’t try the other things, then you would say why didn’t I do all the other things, instead of having surgery?”
He stresses that these other options should be explored but with one eye on the clock, in the full awareness that there is a deadline beyond which even surgery may not send type 2 diabetes into remission, so the final tool – metabolic surgery – must be deployed, whether alone or in combination with other treatments.
Olbers also considers a high and escalating weight to be another trigger for earlier surgery, because the greater the starting weight, the greater the post-treatment weight is likely to be.
The type of treatment algorithm Olbers proposes for adolescents is in line with guidelines published for adults in 2016. However, “I don’t think we are there yet, neither in young people, adolescents, or in adults,” he says. “I hope we can get there in the coming years, but it’s been a little bit like when you have waited a long time and everything has failed, you can consider surgery.”
Changing attitudes
“The main issue,” Olbers believes, “has been the reluctance from society to accept that obesity is a treatment that needs quite serious intervention.”
And on the part of the patients with diabetes, complications appear gradually, with major issues such as kidney failure, cardiovascular problems, neuropathy, and failing sight largely occurring well after the time when surgery could have averted them.
For a person with recently diagnosed diabetes, especially a child, “it is very hard to see that you are coming to that situation,” says Olbers.
Pediatricians also tend toward caution, he notes, being wary of the risks involved in a major operation.
But he says: “I think that there is definitely something happening when you have the pediatrician not having met adolescents who had surgery, and when they meet and follow their first patients. I have seen this […] journey over the 15 years I have been working with it.”
It is one thing to read the study findings, he explains, but quite another to experience firsthand that the adolescent with type 2 diabetes, having undergone surgery, can immediately stop taking insulin. So he finds that pediatricians who have previously had patients go through surgery are much more positive, and are proactive about approaching surgeons to discuss children who may benefit from surgery.
“I think this is probably the journey that all pediatricians need to go through to kind of see; seeing is believing somehow,” Olbers concludes.
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