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| It Really Isn't Always This Clear-cut! From loldiabetes.com |
Why Not??
A recent report may make you think twice.
As you know, the vast majority of Diabetics in the US are of the ever-blossoming Type 2 variety, especially in adolescents, but there are a fair number of overweight / obese Type 1 diabetics out there too.
If you are of the same generation of health care education and training as myself (does "Blue Boaters / Pink Puffers" mean anything to you?), then you will harken back to the fact that most, if not all, type 1 Diabetics are skinny, usually younger, ketosis-prone, etc.
As you have likely experienced in real practice, however, especially in the past few decades, there are also the 'hybrid-like' Type 1s. They tend to be obese, or have a later onset in diagnosis (Type 1 1/2), yet still have marked insulinopenia, and likely have an autoimmune process at root cause for their disease process, thereby primarily destroying their Islet cells as their pathophysiologic insult.
I have reviewed one such patient earlier in this Blog, a true Type 1 that was overweight when she came to see us. She had a Sleeve and did very well, with dramatically reduced insulin needs, improved glucose control, and much improved sense of well-being and lifestyle.
A recently reported small study,
published in the letters to the editor in Diabetes Care, described
some interesting findings.
In the 10 patients retrospectively
studied, all were type 1 Diabetics, as proven by the presence of
Auto Islet Cell antibodies, absence of C-Peptide, and/or documented
history of Ketoacidosis. All patients were followed postoperatively in terms of changes in weight, A1C, insulin
requirements, lipid panels, and blood pressure. The patients surgically underwent a
mix of Bands and Sleeves, but most had Gastric Bypass surgery.
At mean follow-up at 36 mos, BMI was
reduced by 27% on average, and had a mean BMI of 41.6 at the time of
surgery. Nine of the patients at 36 mos had experienced a 60% loss in
their weight.
A1C levels dropped from 10.0% to 8.9%.
Average LDL cholesterol dropped by 23.0 mg/dl, HDL increased by 10.8
mg/dl, and triglycerides dropped by 30. Mg/dl- all significant
changes.
Hypertension resolved or improved in 5
of the 7 patients who had the diagnosis preoperatively, and
albuminuria resolved in 1 of the 2 patients that had
microalbuminuria.
Dr, Brethauer, the lead investigator
for this report, stated that “The findings of this study, the
largest case series of its kind to date (!-my emphasis), indicate that bariatric
surgery leads to a remarkable and sustained weight loss in severely
obese patients with type 1 DM, and results in significant improvement
in their glycemic status and comorbid conditions.”
Obviously, type 1 and type 2 diabetics
are two different animals, for the most part, due to their
presentation, pathophysiology, genetics, and treatment. Where
crossover exists in their clinical status, i.e. for type 1’s that
are significantly overweight, and share then likely share the A1C, lipid, and BP
elevations, keep in mind the proven benefit from the ‘remarkable
and sustained’ weight loss, and likely some additional metabolic
benefit, similar to that seen with the more garden-variety overweight
type 2’s that we much more commonly see.
All in all, we all know the
pathophysiologic consequence manifested by all uncontrolled diabetics that will occur,
sooner or later. Time is not on their side if they consistently do
not get to the goals of BP control, A1C, and lipid levels.
This may
be 'the other' tool to consider when the time is right.
