DR AHMAD ALY DISCUSSES TYPE 2

One of Australia’s pre-eminent upper gastrointestinal surgeons remembers the day when the results from a bariatric surgery patient triggered a reaction that “felt like someone had punched me in the face”.

“I was doing my fellowship in England. There was a patient who had type 2 diabetes and had been on 100 units of insulin a day for the past 12 months,” said Dr Ahmad Aly.

“He’d lived with diabetes for about three years, and his HbA1c ran at about 9%. He came in six months after surgery, off all insulin, with his HbA1c at 5.5%.

“I looked at that and thought, ‘This is ridiculous. You’re essentially ‘cured’ of type 2 diabetes.’ We rarely use the word ‘cure’ [because type 2 can come back if weight is regained] but that was honestly what was going through my head.”

Dr Aly said when he was in medical school no one ever suggested there was a way to put type 2 diabetes into long-term remission. Once diagnosed, you were thought to have the condition for the rest of your life and it would be slowly progressive with complications that can include cardiovascular disease, stroke and more.

“If there’s one area where the effect of bariatric surgery is revolutionary, it’s type 2 diabetes. The impact is profound.”

WHAT IS BARIATRIC SURGERY? Bariatric, weight loss, or metabolic surgery (which all describe the same procedures) has been around for a long time.

The most commonly performed operations for the treatment of obesity in Australia and worldwide are adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and single anastomosis gastric bypass (sometimes called a mini-gastric bypass). The adjustable gastric band involves laparoscopically (through keyhole surgery) placing an adjustable band, commonly called a lap-band, around the top portion of the stomach to decrease food consumption.

The sleeve gastrectomy surgically removes a large portion of the stomach to reduce it to about 15% of its original size. The result is a sleeve or tube-like shaped stomach.

The Roux-en-Y gastric bypass creates a small pouch from the stomach and connects the newly created pouch directly to the small intestine. It results in a marked reduction in the functional volume of the stomach, and a change in the physiological and physical response to food.

A mini-gastric bypass also reduces the size of the stomach and bypasses a stretch of the intestines. This decreases the amount of food that can be consumed and causes some malabsorption of kilojoules, resulting in weight loss.

Both the gastric sleeve and the Rouxen-Y bypass have high success rates of bringing blood glucose levels into a healthy range without medication. The bypass is the most effective procedure for this goal, and achieves it with less medical therapy than the sleeve.

For the purposes of this article, which examines the effects of bariatric surgery on type 2 diabetes, Dr Aly focuses on the bypass and gastric sleeve. Because the mini bypass is a relatively new procedure there is less data on its effectiveness on diabetes.

METABOLIC DISEASE Dr Aly usually refers to metabolic surgery rather than the other descriptions because he believes there is little widespread understanding of obesity and excess weight.

“It’s very clear that excess weight affects metabolic processes – like those involved in causing diabetes,” Dr Aly said. The ways that our body processes glucose and the malfunctions in similar processes is referred to as a metabolic disease.

“Most of the ill-health that occurs with obesity is related to either metabolic changes induced by excess fat or direct effects of excess weight, such as pressure to joints or on internal organs.”

Dr Aly wants all of us to know, whether we live with diabetes or not, that weight gain is often a result of genetic chronic disease and the interplay between genetic and environmental factors.

STIGMA, OBESITY & GENETICS “There’s a stigma around obesity, obesity treatment and surgery because for centuries we’ve had this notion that if you’re overweight or obese, it’s because you choose to be that way,” Dr Aly said with a fierce compassion.

“We’ve come to think it’s caused by a lack of discipline, laziness, gluttony or something like that.

“We’re so conditioned to believe that. It’s very hard to break that belief, and there’s a stigma attached to those beliefs, that we’re ill-disciplined or lazy.

“What we’ve learned in the past 15 or 20 years is that obesity is in fact a genetic, chronic disease. It’s the result of an interplay between your genetics and how that affects your physiological processes and our environment.

“We’re not saying our environment has nothing to do with it: what we’re saying is that you don’t get one without the other.”

Dr Aly goes on to explain that if you have the genetics, but not an environment that promotes eating as a reward, advertising that reinforces the pleasures from unhealthy food, or an era that accepts overweight as the new normal, obesity would not be a problem to the same extent as we see it now. 

“On the other hand, if you have the environment but not the genetic processes or physiology, again, you won’t see obesity manifest.”

Dr Aly concedes it’s a very complex issue, but he wants people who would prosper from bariatric surgery to know that genetics encode nearly everything about us physiologically, including appetite.

That includes the thresholds at which we feel full. People with a genetic disposition towards being overweight or obese will not feel full with a certain pressure of food in their stomach.

“For argument’s sake, one sandwich will not generate enough pressure in one person’s stomach for them to perceive fullness. For someone with my genetic predisposition, the same sandwich will generate the same amount of pressure but my brain will perceive that as being full. It’s all genetically programmed,” he said.

“In the same way, we all have a different sensitivity to touch, for example. That’s genetic. I can feel a certain pressure of touch. You may feel a different pressure of touch. It’s not that any of us are trained for it, or are clever or more selfdisciplined about it.”

Appetite, our sense of fullness and our hunger levels are genetically encoded.

THE ‘SET POINT’ AND APPETITE Dr Aly said our ‘set point’, or the weight that our body wants to sit at, is also genetically coded and regulated by appetite.

“So, if my set point is 80kg, for example, and I start to drift to 75kg my body tries to get back to 80kg and it does that by regulating appetite.

“There are multiple pathways that control appetite and a lot of them are related to the gut.

“Essentially, they’ll switch to make me hungrier and eat more to bring my weight back up to 80kg.”

Dr Aly said why the set point is at a certain weight is still a mystery, but what is clear now is that the body will always try to get back to that set point and regulates it through multiple physiological processes that control appetite and fullness.

“When we get to food, do you really think your body is going to let you decide when and how much you eat? To have complete control over that? It won’t.

Dr Aly stresses that this happens because the body is self-preserving, regardless of what our head wants us to do.

HIERARCHY OF NEEDS He explains that there is a hierarchy of needs for a human to survive. The heart rate is at the apex, followed by breathing, then the need for food and water.

“Heart rate is controlled extremely precisely by physiological processes. Your willpower, your consciousness, your thinking cannot alter it. You can relax, slow your heart rate a little, but you can’t will it to stop.

“It’s the same with breathing. No matter how disciplined or what willpower you have, your body will force you to breathe.

“When we get to food, do you really think your body is going to let you decide when and how much you eat? To have complete control over that? It won’t.

“The physiology is going to make you survive. The level of control is a bit more lenient, just like breathing over heart rate.

“Yes, you can calorie restrict and you will lose weight, but your physiology will shift to make you hungrier and hungrier and hungrier. It will keep on dripping like a tap until you eat and bring your weight back up to where your set point is.”

WHEN TO CONSIDER SURGERY Dr Aly said treating obesity was like treating any other chronic disease: there is a range of treatments.

“If someone comes to you with arthritis in the knee, you don’t start with knee replacement surgery. You might start with physiotherapy and get muscle strengthening exercises so that the joint isn’t under stress. You might be prescribed anti-inflammatories, or you

might end up with an arthroscopy, and if those treatments don’t work, you might progress to surgery.”

Whether surgery is the right option for an individual depends at what stage a patient presents with the disease.

“If they’re already in extremis with their obesity, have significant ill-health and metabolic disease [such as type 2 diabetes], and have already tried other treatments, it’s entirely appropriate to go to surgery.”

He said that by the time patients are examining surgery as an option, they’ve usually been through all other possible treatments because people don’t jump to surgery as a first option.

COST Dr Aly’s conviction that bariatric surgery is a necessary treatment choice for people with type 2 diabetes has prompted him to campaign and join efforts such as submissions to government to get access to these procedures extended.

At present, 90% of all bariatric surgery is done privately because there isn’t enough funding for it in the public sector. Put simply, it’s unavailable to most patients in the public system.

The cost in the private sector ranges between $20,000 to $28,000, including hospital stay. Private medical insurers will pay most of this cost if members have the Gold level of care.

Some people choose to draw down on their superannuation to pay for the surgery or the gap, while others choose a medical loan.

COMPLICATIONS Complications of bariatric surgery include post-operative bleeding and leaks of stomach acid into surrounding tissue from wounds. The rate of a serious adverse event resulting from primary bariatric surgery recorded on the national Bariatric Surgery Register “There’s a stigma around obesity, obesity treatment and surgery because for centuries we’ve had this notion that if you’re overweight or obese, it’s because you choose to be that way.

is 2.1%. The death rate is about 0.2%. These rates rise if revision surgery is necessary following the procedure.

TYPE 2 DIABETES & REMISSION It’s also worth noting that the rate of long-term remission for people with type 2 diabetes after bariatric surgery depends on how soon after diagnosis of their diabetes they undertake surgery.

“The studies are consistent. There are very high rates of long-term remission if you catch the diabetes in the first five years. After that, the pancreas can get burned out. We still see remission, we still see reductions in medication requirements, we see improvements in HbA1c and glucose control.

“But it gets harder to achieve longterm remission and medication reduction the longer the patient has had diabetes because the pancreas simply can’t produce the insulin. It’s been damaged too much.”

Dr Aly refers to the 5-year outcomes published in the Stampede study by Dr Philip Schauer and others. The study finds that people who undergo the gastric sleeve or bypass achieve remission from diabetes at a much higher rate than those who try intensive medical therapy only. Five years after the surgical procedures the rate of type 2 remission was 89%.

FINAL WORDS Despite believing that bariatric surgery is the most effective treatment to achieve remission from type 2 diabetes, Dr Aly believes it’s up to the individual to decide if the risk of surgery is worth the benefit.

What he would like everyone to know is that the belief that long-term obesity is a personal choice is, in the vast majority of cases, mistaken.

“A lot of people feel an extreme sense of failure by the time they’re sitting in my office. They’ve tried everything and it hasn’t worked to reduce weight.

“They’ve grown up with the stigma and the belief that it’s all their fault, that they had a choice, that it was all up to them.

“That’s why we have tissues on my desk. It’s usually the first time someone has told them ‘It’s not all your fault’.” n

Rachelle uses surgery to help with her diabetes

Rachelle is a data analyst at Diabetes Queensland Rachelle Swan’s face creases into a smile as soon as she sees you. Perhaps it’s her warmth that stopped people realising she was medically obese when she chose to have weight loss surgery.

“I’d get annoyed when people would say ‘You don’t need to do that.’ I have type 1 diabetes and I was medically obese. I really wanted to have this surgery.”

Rachelle, who was diagnosed with diabetes 38 years ago when she was 11, put on nearly 10 kilograms during the first six months of the COVID lockdown last year. She is 170cm tall and weighed 98 kilos at her heaviest, with a BMI of nearly 34.

She was getting more and more worried about the effect of her excess weight on her diabetes.

“I’m an overthinker. I’m also an emotional eater. I was worried about the complications of diabetes all the

time. Worrying about it just made me feel worse. I knew I wasn’t looking after myself and that made me worry, so I ate more.

“No matter how hard I tried, I kept putting on weight. I needed help.”

Rachelle is a passionate long-term netball coach and office bearer for her local club and association. With two adult children, full-time work and netball, there isn’t a lot of time in her week to sit around contemplating things.

“I saw a Facebook ad that invited me to look at a presentation on the internet. From there I spoke to a nurse who works in the same practice as the surgeon I used, then a psychologist.

“They want to find out if you’re ready to commit to the changes necessary for the surgery to be a success.”

Rachelle was operated on by Dr Reza Adib last year for a gastric sleeve, which drastically reduces the size of a patient’s stomach.

“I had no alcohol or soft drinks for 14 days and finished a week of Very Low Calorie shakes before surgery,” Rachelle said. “If they told me to do it, I did it. I didn’t want them to refuse to do the surgery because I hadn’t completed the preparation.”

Rachelle lost six kilos during her preop week of diet shakes but she never considered withdrawing from surgery because of this success.

Like many people who undergo weight loss surgery she had lost weight on shakes before but she always put it back on, with a little extra, when she reverted to normal eating.

The biggest driver for Rachelle was that she felt her diabetes wasn’t well managed. Rachelle’s highest HbA1c before surgery was just short of 9%, and she was taking 15 units of basal (longlasting) insulin every morning and night. Her ratio for short-acting insulin (bolus) was 2:1 at breakfast, and 1:1 at lunch and dinner.

“I sent my diabetes educator and endocrinologist all the information about the operation and asked for advice about what to do on the day of and after the surgery.

“To be honest, I didn’t ask for their advice about whether I should do the surgery or not. I notified them I was doing it because I’d decided it was the right thing for me.”

Rachelle was shocked by how rough the first couple of days were after surgery.

“I had some good friends who had it done before me but they didn’t experience what I went through so couldn’t have warned me.

“The pain the first day was horrendous. I wasn’t expecting it. From the moment I woke up I was vomiting, but that wasn’t the major issue. It was the pain in my stomach after the surgery that was hard.”

Rachelle said it took her about three months to feel fully 'human' again, but it was only the first couple of days that were really tough. Rachelle, who is also coeliac, now eats five small meals a day and tries to maximise her nutritional intake with every meal. A typical day starts with a small portion (about 200 grams) of porridge for breakfast with skim milk, an egg or a small handful of almonds and cashews at morning tea, pre-cooked chicken stir fry with vegetables,or something similar, for lunch, grapes for afternoon tea, and vegetables with protein for dinner.

Rachelle said the biggest danger to her after the operation and reduced food intake were hypos at night.

“I had a hypo most nights after the operation whereas before I’d only have one if I miscalculated my insulin. I used my Freestyle Libre [flash glucose monitor] because I felt that was a safer option. I could just run my phone over the sensor to get a reading quickly.

“That allowed me not to worry so much about hypos while I was gradually reducing my night-time insulin.”

Rachelle said she had to factor in the cost of the sensor at $92.50 every fortnight, which she found extremely expensive “but it was a necessity to use”.

Nine months after surgery, Rachelle weighs 74.6kg and wants to lose another 4.6kg. Her last HbA1c was 7.5% and she has reduced her long-lasting insulin to 11 units in the morning from 15 units twice a day pre-operation. Her short-acting insulin is about the same, except for her night-time ratio dropping from 1:1 to .5:1.

“It’s the best thing I ever did. I’ve got a new lease on life and I’m going to enjoy it.

“It was my body, my decision. It’s been the right one for me.” n

“They want to find out if you’re ready to commit to the changes necessary for the surgery to be a success.

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WHAT IS DISORDERED EATING? Disordered eating is problematic eating behaviour that occurs with varying severity. It includes restricting food, skipping meals, excessive or compulsive eating or exercise, binge eating, laxative/diuretic abuse, vomiting and/or reducing or omitting insulin doses for the purpose of weight control.

Disordered eating and type 1 diabetes

If you have type 1 diabetes and struggle with disordered eating or an eating disorder, you are not alone and it is important to seek support, writes Helen d’Emden AdvAPD, CDE

In the past 30 years there has been growing awareness that people living with type 1 diabetes have higher rates of disordered eating and eating disorders. We have also learnt more about why those with type 1 diabetes are at increased risk of disordered eating. More recently health professionals are working to upskill to better support individuals with or at risk of disordered eating.

The health consequences of disordered eating can be serious, especially if the reduction or omission of insulin is involved. This is why any problems are best addressed as early as possible. The longer you delay seeking help the more entrenched the behaviours can become.

The book Prevention and Recovery from Eating Disorders in Type 1 Diabetes – Injecting Hope, written by psychologist Dr Ann GoebelFabbri, tells the story of 25 women aged 18-50 years who live with type 1 diabetes and have recovered from an eating disorder. On average the women had lived with type 1 diabetes for 19 years and had experienced disordered eating for eight of these years. Importantly, 23 of the 25 women believed the eating disorder was preventable.

There are many learnings that have come from this book for both health professionals and for those with type 1 diabetes who are struggling with their eating. For those with diabetes, it is essential to find a collaborative health care team who understand both type 1 diabetes and disordered eating.

Your health care providers should be alert to the signs and symptoms of disordered eating, and be prepared to discuss this with you. Relationships with health care professionals must be trusting and respectful, so open and honest communications result. If you are experiencing some form of disordered eating, it is important to discuss this with someone in your health care team that you trust and feel comfortable with.

Your health care professionals should clearly advise you that the treatment goals of type 1 diabetes are not to make you overweight. Your weight concerns should be taken seriously and not dismissed, as your concerns are as valid as for someone without diabetes.

Your health team should also give factual information of the risks of insulin omission, and the signs and symptoms of diabetes ketoacidosis so this lifethreatening condition can be avoided.

Depending on your individual needs, additional education and assistance from a psychologist, dietitian or diabetes educator can help.

If you’re struggling with disordered eating and eating disorders  Find a supportive and knowledgeable health care team  Be prepared to tackle your concerns in small manageable steps  Talk to your loved ones about how best they can support you

Be assured you are not alone, and this problem is now recognised. Life can be better, and with the right care and support there is an easier way forward with better health outcomes for you. n