Journal of Diabetes 3 (2011) 261–264

COMMENTARY

Bariatric surgery for diabetes: The International Diabetes

Federation takes a position
John B. DIXON,1 Paul ZIMMET,1 K. George ALBERTI,2 Jean Claude MBANYA3 and
Francesco RUBINO4 on behalf of the INTERNATIONAL DIABETES FEDERATION TASKFORCE
on EPIDEMIOLOGY and PREVENTION
1
Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia, 2Imperial College London, St Mary’s Hospital Campus, London, UK,
3
Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon and 4Weill Cornell Medical College of Cornell
University, New York, New York, USA

Correspondence
Paul Zimmet, Baker IDI Heart & Diabetes
Institute, PO Box 6492, St Kilda Road
Central, Victoria 8008, Australia.
Tel.: +61 3 8532 1818
Fax: +61 3 8532 1718
Email: paul.zimmet@bakeridi.edu.au
Received 20 June 2011; accepted 22 June
2011.
doi: 10.1111/j.1753-0407.2011.00144.x
Abstract
Type 2 diabetes (T2D) and obesity are both complex and chronic medical
disorders, each with an escalating worldwide prevalence. When obesity is
severe, and ⁄ or available medical therapies fail to control the diabetes, bari-
atric surgery becomes a cost-effective therapy for T2D. When there are
other major comorbidities and cardiovascular risk, the option of bariatric
surgery becomes even more worthy of consideration. National guidelines
for bariatric surgery need to be developed and implemented for people with
T2D. With this in mind, the International Diabetes Federation convened a
multidisciplinary working group to develop a position statement. The key
recommendations cover describing those eligible for surgery and who
should be prioritized, incorporating bariatric surgery into T2D treatment
algorithms, performing surgery in centers with multidisciplinary teams that
are experienced in the management of both obesity and diabetes, and
developing bariatric surgery registries and reporting standards.
Keywords: gastric, guidelines, registry, surgery, weight loss.

vention into a public health, clinical, and socioeconomic

Introduction
The emerging role of bariatric surgery in the manage-
ment of Type 2 diabetes (T2D) in obese people
prompted the International Diabetes Federation (IDF)
Taskforce on Epidemiology and Prevention of
Diabetes to convene a consensus working group of
diabetologists, endocrinologists, surgeons, and public
health experts to develop a position statement on the
topic.1 The specific goals were as follows:
1. To develop practical recommendations for clinicians
regarding patient selection.
2. To identify barriers to surgical access.
3. To suggest interventions for health policy changes
that ensure equitable access to surgery when
indicated.
4. To identify priorities for research.
A major reason for producing the IDF Position
Statement was the need to place the role of bariatric inter-
perspective; it had become a ‘‘last resort’’ rather than an
option to consider earlier in the management of T2D.
Obesity and T2D are very closely related chronic
conditions that are rising dramatically in prevalence
and generating major global health issues.2,3 Although
population-based initiatives must be pursued to pre-
vent the onset of obesity and T2D, at the same time
effective treatment must be available for people who
develop T2D.
Bariatric surgery was originally developed to treat
clinically severe obesity. It should now be considered as
a component of regimens to complement (but not
replace) lifestyle measures and established medical ther-
apies in the management of obese patients with T2D.
This is based on evidence showing that surgery has the
ability to improve glycemic control, other comorbidities,
and quality of life, as well as reducing macrovascular
morbidity and mortality.4,5 The recommendations

ª 2011 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Blackwell Publishing Asia Pty Ltd 261
Commentary
provided by the IDF apply to established bariatric pro-
cedures, such as Roux-en-Y gastric bypass (RYGB) and
adjustable gastric banding (AGB), and not, for the pres-
ent, to novel procedures and devices while awaiting their
longer-term outcomes.1
Current blood glucose-lowering therapy
Given the role of obesity in the etiology of T2D,
weight loss provides the most logical treatment.6 A
number of current therapies for T2D induce weight
gain, something that is counterintuitive for treating
T2D. Early, more intensive therapy of T2D has been
recommended to reduce end organ damage and to
prevent long-term vascular morbidity and mortality,7
but for obese patients with diabetes, clinical inertia
and frustration are associated with repeated failure of
lifestyle programs to achieve sustained weight loss.
Failing to lose weight and keep it off is the norm,
for many physiological reasons, but obese people with
T2D are instead labeled as poorly compliant and ⁄ or
poorly motivated, as if they were demonstrating
psychological or behavioral weaknesses. Current weight
loss medications are few and of limited benefit,
whereas poor glycaemic control leads to the eventual
introduction of poly pharmacy, which, unfortunately,
is often accompanied by weight gain. Treating people
with diabetes and severe complex obesity is challeng-
ing and targets are difficult to achieve.
The evidence
The available evidence indicates that bariatric surgery
is the most effective treatment for achieving and sus-
taining significant weight loss. It can result in major
improvements in glycemic control or even remission
of diabetes in most people with diabetes. It also
improves other important obesity-related conditions,
including dyslipidemia, sleep apnea, and hypertension,
reduces cardiovascular risk, and improves quality of
life.8,9 When those with clinically severe obesity are
treated with bariatric surgery, there is a reduction in
overall mortality compared with severely obese com-
munity controls receiving usual care. Specific reduc-
tions in cardiovascular disease, cancer in women, and
diabetes-related mortality are the most marked.5,10
Morbidity and mortality associated with current
conventional bariatric procedures, such as RYGB and
laparoscopic AGB, is generally low and similar to
that of gallbladder surgery.1,11 Evidence to date also
indicates that bariatric surgery for obese patients
with T2D is cost-effective and, in some analyses,
cost-saving.12,13 However, these health economic
262 ª 2011 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Blackwell Publishing Asia Pty Ltd
studies have not been conducted in most low- and
middle-income countries where high cost interventions
may not be available.
Patient selection
Bariatric surgery is an appropriate treatment for peo-
ple with T2D and obesity who are not achieving rec-
ommended treatment targets with existing medical
therapies, especially in the presence of other major
comorbidities. The IDF recognizes that for economic
and regional reasons, bariatric surgical services may be
limited and identifies two categories of indication:
(i) those broadly eligible for surgery; and (ii) others
who should be prioritized in view of disease severity
and the high likelihood of benefit. In patients with
T2D, eligibility or prioritization for surgery should
consider body mass index (BMI), ethnicity, associated
weight-related comorbidity, weight trajectory, and the
current response of diabetes and other comorbidities
to optimal medical therapy (Table 1). Surgery should
be considered and not unduly delayed when patients
are eligible or prioritized, because delays reduce the
likelihood of major improvement or remission, possi-
bly due to progressive loss of pancreatic b-cell func-
tion.14,15 Health-care services need to consider equity
of access for those most in need, and societal preju-
dices regarding obesity should not act as a barrier to
the provision of effective treatment options, including
bariatric surgery.
Table 1 Eligibility and prioritization of patients with Type 2 diabe-
tes for bariatric surgery,1 based on failed non-surgical weight loss
therapy,* body mass index, ethnicity,  and disease controlà
Eligible Prioritized
BMI (kg ⁄ m2) for surgery for surgery
<30 No No
30–35 Yes: Conditionalà No
35–40 Yes Yes: Conditionalà
>40 Yes Yes
*In all cases, patients should have failed to lose weight and sustain
significant weight loss through non-surgical weight management
programs and have Type 2 diabetes that has not responded
adequately to lifestyle measures (with or without metformin) with
an HbA1c <7%.
Action points should be lowered by 2.5 body mass index (BMI)
point levels for Asian populations.20
à
Conditional upon HbA1c >7.5% despite fully optimized conven-
tional therapy, especially if weight is increasing, or other weight
responsive comorbidities not achieving targets on conventional
therapies (e.g. blood pressure, dyslipidemia, and obstructive sleep
apnea).

Currently, <1% of those who are either eligible
or prioritized for bariatric surgery have this therapy
considered.16 National guidelines for bariatric surgery
in people with T2D and a BMI of at least 35 kg ⁄ m2
need to be developed and actively promulgated. In
addition, the option of surgery needs to be incorpo-
rated into national and international algorithms for
the management of T2D in patients with obesity.
Obese people with diabetes should be aware of all
available therapies, including surgery, and receive well-
informed counseling about surgical options.
Of course, it is up to each country to determine
whether bariatric surgery, with its associated essential
support services, is economically appropriate. Where
resources are limited, bariatric surgery should only be
performed when health budgets can afford it and the
expertise for both surgery and long-term follow-up is
available.
Recommendations for surgical management
Bariatric surgery for T2D with obesity must be
performed within accepted guidelines. Surgery should
be performed in high-volume centers with multi-
disciplinary teams that are experienced in the manage-
ment of chronic obesity and diabetes, as well as the
surgical procedures themselves.
The multidisciplinary teams need to provide compre-
hensive patient assessment, counseling, and education,
and optimize health prior to surgery. Postoperatively,
the team must provide patients with ongoing education
and care, with a focus on enhancing behavioral
change, recognizing surgical complications, monitoring
diabetes and other comorbidities, and providing nutri-
tional and psychological assessment and support. Life-
long follow-up on at least an annual basis is needed
for continuing lifestyle support, as well as post-surgical
and diabetes monitoring.
The IDF calls for the establishment of national
registers of people who have undergone bariatric
surgery to ensure quality patient care and the
monitoring of both short- and long-term outcomes.
Details about the presence of T2D and progress with
the condition would be a crucial component in such
registries.
Selection of an established surgical procedure
The established procedures, which include RYGB and
AGB, vary in their efficacy, safety, and mechanism of
action for the improvement of glycemic control. The
more complex diversionary procedures, such as gastric
bypass and biliopancreatic diversion, provide rapid
ª 2011 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Blackwell Publishing Asia Pty Ltd
Commentary
improvement in glycemic control beyond the effect of
weight loss alone. This appears to be an incretin effect,
but other mechanisms may also be involved.17,18
A central part of the process for selecting the appro-
priate surgical treatment options is an assessment of the
risk versus benefit of each operation for each individual
patient. Selecting the procedure may be influenced by
available surgical expertise, the patient’s general health
and operative risk,19 the duration of diabetes, estimates
of the degree of residual b-cell function and, of course,
patient preference.
Future directions
Several novel surgical gastrointestinal procedures and
devices are under development.1 These new bariatric
procedures and devices should be explored in the
research setting only. They require robust assess-
ment of efficacy and long-term benefit, safety, and
durability, using similar principles to those for the
assessment of new drugs, with careful consideration
of the benefits and risks compared with established
therapy.
The IDF has identified the following priorities for
future research.
1. Establishing more robust criteria for patient
selection and prioritization, matching patient profile
to procedure, and establishing the benefits of sur-
gery in those with a BMI <35 kg ⁄ m2.
2. Testing the durability of surgery and establishing its
effect on progressive loss of b-cell function and
microvascular complications.
3. Preclinical studies to explore the mechanism of
action of gastrointestinal interventions and to test
new surgical procedures and devices.
4. Clinical studies to establish the mechanisms of
surgical success and failure, the best regimens for
diabetes management after bariatric surgery, and
the long-term complications of surgery.
5. Randomized controlled trials to evaluate and
compare different bariatric procedures for the
treatment of diabetes between themselves, as well as
against emerging non-surgical therapies.
Acknowledgments
The consensus meeting was supported with an
unrestricted educational grant by Allergan Inc.
(Irvine, CA, USA), Ethicon, Ethicon Endo-Surgery,
Inc. (Cincinnati, OH, USA), and MetaCure Inc.
(Mount Laurel, NJ, USA). These companies played
no role in the discussion or preparation of this posi-
tion paper.
263
Commentary
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