A Comment on the International Diabetic Federation Statement

Abstract

To the Editors Dr. Walter Pories, a great pioneer in the development of bariatric into metabolic surgery [1], has provided major suggestions [2]) to the recent International Diabetes Federation (IDF) guidelines for metabolic surgery for type 2 diabetes (T2D) [3]. The remission of T2D after weight loss operations has long been recognized [4, 5], but the formal IDF position statement is a milestone. Importantly, Nicola Scopinaro, performing biliopancreatic diversion, has found an extremely high remission rate for T2D in diabetics with lower BMI [6]). There is one instance where the IDF guidelines require some caution. The position statement mentions in a table on management of diabetes near the end that there should be an audit of C-peptide and autoantibody status, e.g., antiGAD where available [3]). However, this assertion is not explained. A problem which can harm the use of metabolic surgery for meaningful remission of T2D is if the patient actually has a type 1 diabetes. Latent autoimmune diabetes in the adult (LADA) may have slow onset generally between ages 30 and 55, at any weight, and will ultimately progress to requiring insulin [7]. LADA is an explanation for some cases of diabetes at lower BMI. This type 1 diabetes should be diagnosed by very low fasting and/or meal-stimulated C-peptide (≤1 ng/ml), low plasma insulin, and presence of autoantibodies to glutamic acid decarboxylase (GAD), islet cells, insulin and/or insulin A2 [8]. These patients have relentless autoimmune destruction of the pancreas and may have other autoimmune disorders. Lee, Boza and Basso’s groups [9–11] exclude diabetic patients with low C-peptide (an indication of low beta-cell function) from bariatric metabolic surgery. Longstanding uncontrolled T2D with HbA1c of 10, despite initial insulin resistance/hyperinsulinemia, will eventually be unable to increase insulin response to signaling, as a result of betacell apoptosis [5]). This T2D will require insulin. However, Shashank Shah has noted that in those South Asian diabetics whose BMI is lower and have a lower body fat percentage (personal communication, Sept. 28, 2011), type 1 diabetes must be considered [12]. For metabolic operations to result in a significant and sustained remission of diabetes, especially in those presenting with lower BMI, adult-onset type 1 diabetes should first be ruled out.