Bariatric surgery: a metabolic solution or a paradigm for novel treatment options?

In general, quality of life in morbid obesity is decreased, which is well demonstrated by the findings that patients seeking weight loss surgery are on average willing to accept a 13% risk of death to achieve their most desired health or weight state. Social stigma or public distress, and the interference of role functioning due to physical limitations, are reported to be the major determinants of their lower quality of life. 2 Worldwide, a large number of patients undergo bariatric surgery to mitigate obesity-related complications. Metabolic surgery, as bariatric surgery is also called, has indeed been demonstrated to significantly improve or resolve cardiometabolic complications of obesity, such as type 2 diabetes (T2D), hypertension, and dyslipidaemia, as well as sleep apnoea and psychological disturbances. 3 With respect to T2D, a recent meta-analysis showed that the overall T2DM remission rate in the first 12-24 months after surgery is 63.5%. 4 An intriguing aspect of bariatric surgery is that it greatly improves glycaemic control, often within days after surgery, and out of proportion to postoperative weight loss. 5 Therefore, in the clinical practice of bariatric surgery for patients with insulin-dependent T2D, the dosages of insulin used should be reduced to prevent postoperative hypoglycaemia. Cruijsen et al. show in their study in this issue of the Netherlands Journal of Medicine that an insulin dose reduction of 75% may be safe, as shown by the observations that no hypoglycaemic events occurred in the early postoperative phase, and 26% of all glucose measurements on the day of surgery and only 4% of the measurements one week after discharge were …