Bariatric Surgery for Severe Obesity in Two Adolescents With Type 1 Diabetes

Abstract

Bariatric surgery has been effective in treating type 2 diabetes mellitus (T2DM); it has not been used frequently in obese patients with type 1 diabetes mellitus (T1DM). This is the first case series reporting on the effect of bariatric surgery on diabetes control in adolescents with T1DM. Patient A is a 19-year-old obese man with T1DM who underwent vertical sleeve gastrectomy. At 12 months after surgery he demonstrated 28% reduction in BMI. His daily total insulin requirement had decreased; however, hemoglobin A1c remained primarily unchanged at 8.8%. Patient B is a 13-year-old obese girl with an initial clinical diagnosis of T2DM controlled on only metformin. She underwent Roux-en-Y gastric bypass; at 1 month after surgery she presented in diabetic ketoacidosis and was found to have positive islet cell antibodies, which were also present before surgery. Her diagnosis was revised to T1DM, and she was started on insulin. By 28 months after surgery her BMI had decreased by 42%. Since initiation of insulin, her daily total insulin requirement had decreased, but hemoglobin A1c had significantly worsened from 6.3% to 10%. We found that despite significant weight loss, improvements in cardiovascular risk factors (dyslipidemia and obstructive sleep apnea), and quality of life in our patients, bariatric surgery does not necessarily lead to improved glycemic control of T1DM. Patients with T1DM have ongoing dependency on exogenous insulin, and optimal glycemic control still depends on patient compliance with diabetes care. Pediatrics 2013;132:e1031-e1034 Dr Chuang conceptualized the case series and drafted the initial manuscript; Dr Zeller interpreted the quality of life measurements used in the case series, wrote the interpretations for the manuscript, and reviewed and revised the manuscript; Dr Inge helped obtain data used in the case series and critically reviewed and revised the manuscript; Dr Crimmins help conceptualize and design the outline for the case series and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

Outcome of bariatric surgery in patients with type 1 diabetes mellitus: our experience and review of the literature

“…Most evidence to support BS in T1DM is derived from small case series or case reports (Table 1) [7][8][9][10][11][12][13][14][15][16][17][18][19][20]. The data are also limited by a number of factors: heterogeneous data, short follow-up periods and inclusion of different types of surgery.…”

“…Moreover, nonobese T1DM patients have an increased risk of obesity due to the anabolic effects of insulin and due to their frequent use of simple sugars for hypoglycemic episodes [6]. However, the medical literature which describes BS in T1DM patients is limited to few case series and scattered case reports, with conflicting results (Table 1) [7][8][9][10][11][12][13][14][15][16][17][18][19][20].…”

Bariatric Surgery in Obese Patients With Type 1 Diabetes

“…In one comparative series, remission rates of hypertension and dyslipidemia were similar among patients with T1D and T2D after bariatric surgery (31). A few studies also reported evidence of improvement in sleep apnea (31,43), kidney function and microalbuminuria (30,33,38,39,45), retinopathy (33), and quality of life (38,41,43) after surgery. A reduction in the number and dosage of medications needed to treat diabetes, hypertension, dyslipidemia, and other obesity-related comorbidities following bariatric surgery would be an additional benefit (22)(23)(24)27,32).…”

“…Such beneficial effects on obesity-related comorbidities can also be extrapolated to severely obese patients with T1D. Improvement in lipid profile (30)(31)(32)(33)38,39,(41)(42)(43)(44) and blood pressure (30,31,38,39,41,45) was shown in some studies. In one comparative series, remission rates of hypertension and dyslipidemia were similar among patients with T1D and T2D after bariatric surgery (31).…”

“…Correct diagnosis of T1D in the presence of severe obesity, combining insulin secretory defects and insulin resistance, can be difficult (11,32,43). According to the International Diabetes Federation statement on the role of bariatric surgery in the management of diabetes, fasting insulin, C-peptide, and pancreatic autoantibody status (islet cell and glutamic acid decarboxylase) should be checked before bariatric surgery (47).…”