managing type 2 diabetes

Research shows that gastric banding surgery can be more cost-effective for managing type 2 diabetes in obese individuals than conventional care

Research led by the Centre for Obesity Research and Education (CORE), Monash University, Melbourne

World-first research reveals laparoscopic (keyhole) adjustable gastric banding (LAGB) surgery is more cost-effective than conventional weight loss methods for managing recently diagnosed type 2 diabetes in the obese.1,2

The landmark research, conducted by Monash and Deakin Universities and published in the American Diabetes Association's journal, Diabetes Care, recorded some dramatic findings regarding the potential health benefits and healthcare cost-savings to be gained by substituting LAGB surgery for conventional care (diet, exercise and medication) in managing type 2 diabetes in obese patients.1

According to Associate Professor John Dixon, formerly from the Centre for Obesity Research and Education (CORE) and now at the Baker IDI Heart and Diabetes Institute, Melbourne, the new research demonstrates the cost-effective benefits of LAGB surgery.

"Previously we and other researchers have shown that weight loss following gastric banding surgery improves health, enhances quality of life and saves lives.

"This new research now shows that it is also cost-effective and saves our healthcare system money.

"There are very few treatments today that do all of this," said A Prof Dixon.

"From a strictly cost perspective, (excluding the important quality of life and life expectancy benefits of diabetes remission), our new research presents strong evidence to show that after 10 years, the return on investment of gastric banding surgery is fully recouped through savings in healthcare costs from treating type 2 diabetes," said A Prof Dixon.

Ms Catherine Keating, Study Investigator and Research Fellow, Health Economics Unit, Deakin University said, "Our research shows that it costs less to treat type 2 diabetes early through gastric banding surgery than to allow the same person to live their life with the disease and face ongoing escalating treatment costs.

"Most importantly, these patients could enjoy a dramatic improvement in their quality of life because early treatment using gastric banding surgery results in remission of diabetes for many patients."

The study found that the lifetime healthcare costs were AUD2,400 less per surgical patient compared to conventional care and that these patients were also five times more likely to experience the quality of life and life expectancy benefits of diabetes remission.1,3

"This study only considered the costs of treating type 2 diabetes, but weight loss has many additional benefits which make it even more cost-effective," said Ms Keating.

"So it is of real value to the community as there will be healthier people at less cost."

"It is fairly rare to assess a healthcare intervention that offers both health benefits and saves healthcare costs."

About the research
The Australian research, comprising two health economics studies, followed a group of 60 obese adults living with the increasingly common combination of obesity and recently diagnosed type 2 diabetes during a two year trial. Each patient was randomised to either LAGB surgery or conventional diabetes treatment. The research reported the actual costs and diabetes outcomes over the two year trial and also predicted the costs and diabetes outcomes over a patient's lifetime.1,2

The research was based on an Australian randomised controlled trial, published in the prestigious Journal of the American Medical Association (JAMA) last year which found that LAGB surgery led to the remission of type 2 diabetes among 22 of the 30 patients, compared to four out of 30 patients who undertook conventional care (diet, exercise and medication).4 Therefore LAGB surgery was five times more likely to resolve diabetes.3 Previous research has demonstrated that remission from diabetes with LAGB surgery can be maintained beyond a decade.4

Pioneer of the LAGB, Head of the Centre for Obesity Research and Education (CORE) at Monash University, Melbourne, and study co-author, Professor Paul O'Brien, said, "This study presents strong evidence to support the cost-effectiveness for early consideration of surgically-induced weight loss in treating obese patients with type 2 diabetes.

"We know that obese people with type 2 diabetes have a difficult time losing weight.

"While we are not advocating that gastric banding surgery is for everyone, it should be considered as a viable, long-term treatment option for those who have tried to shed weight by simpler means," said Prof O'Brien.

"This study provides the first robust clinical and economic evidence to support gastric banding surgery receiving attention within diabetes management guidelines as an effective treatment option.

Prof O'Brien said that while the cost-savings between LAGB surgery and non-surgical care may seem relatively small at first glance, the savings to be recouped in the longer-term are genuinely substantial because a serious disease has been controlled.

"Health economics drives a lot of clinical decisions. That's why these findings are of real value to the community, because we achieve greater health in the community while saving money at the same time," Prof O'Brien said.

About diabetes
It is estimated that diabetes affects around 1.7 million Australians, of whom 85-90 per cent have type 2 diabetes.5Every year, about 100,000 Australian adults develop diabetes.5 Type 2 diabetes is often linked to obesity and high blood pressure.6 In fact, half of those diagnosed with type 2 diabetes are obese.3 Australia's prevalence of diabetes is one of the highest recorded for a developed nation.7 Type 2 diabetes costs the Australian community around $10.3 billion each year.5 The individual healthcare costs for people with diabetes and associated complications, can be up to 26 times higher than the healthcare spending of people without diabetes.9 Type 2 diabetes, together with obesity, are likely to be the two greatest public health problems of the coming decades.3

About the laparoscopic adjustable gastric band (LAGB)
The laparoscopic adjustable gastric band (LAGB), officially known as the LAP-BAND� System, is a buckle-design band placed laparoscopically around the stomach to create a smaller sized stomach pouch.10 It has a soft lining that can be inflated with saline to change the size of the stomach pouch.10 This adjustment is done through an access port in the abdomen, without additional surgery.10

The LAP-BAND� System works in two ways to prevent excess food consumption:
� It creates a small pouch which minimises the amount of food that may be eaten
� The band presses on the stomach, sending signals to the brain that the stomach is full, preventing pangs of hunger.11

The LAP-BAND� System does not involve cutting or stapling of the stomach.10 Because it is performed laparoscopically through small incisions in the abdomen, this permits a quick recovery, with most patients spending only a day in hospital.12

The LAP-BAND� System is suitable for severely obese adults* who have unsuccessfully tried other methods to lose weight, such as diet and exercise.10

Research has shown that people who lose a substantial amount of weight with the LAP-BAND� System have a 72 per cent chance of living longer than obese people who have not achieved significant weight loss.13 Typically, LAP-BAND� System recipients lose an average of 26kg in weight in the first 12 months.14

Complications associated with gastric banding surgery include risks from the medications and methods used in the surgical procedure, the risks associated with any surgical procedure, and the patient's degree of intolerance to any foreign object implanted in the body.10
* Body Mass Index (BMI expressed in kg/m2) > 35 with a serious Comorbidity or BMI > 40

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References
1. Keating CL et al. Cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes: modelled lifetime analysis. Diabetes Care 2009 Jan 26. [Epub ahead of print].
2. Keating CL et al. Cost-efficacy of surgically induced weight loss for the management of type 2 diabetes: randomised controlled trial. Diabetes Care 2009 Jan 26. [Epub ahead of print].
3. Dixon JB et al. Adjustable gastric banding and conventional therapy for type 2 diabetes - a randomised controlled trial. JAMA 2008. 299(3): 316-323.
4. Sjostrom et al. Effects of bariatric surgery on mortality in Swedish obese subjects. NEJM 2007. 357:741-752.
5. Diabetes Australia. Diabetes Action, Diabetes Data. Diabetes Australia Canberra 2008.
6. Australian Institute of Health and Welfare 2008. Diabetes: Australian Facts 2008. AIHW Cat. No CVD 40 (Diabetes Series No. 8) Canberra AIHW.
7. Dunstan D et al. The rising prevalence of diabetes and impaired glucose tolerance. The Australian diabetes, obesity and lifestyle study. Diabetes Care 2002. 25(5): 829-834.
8. Colagiuri S et al. DiabCo$t Australia: Assessing the burden of type 2 diabetes in Australia. Diabetes Australia. Canberra, December 2003.
9. Ramsey SD et al. Patient level estimates of the cost of complications in diabetes in a managed-care population. Pharmacoeconomics 1999. 16(3): 285-295.
10. LAP-BAND AP� Adjustable Gastric Banding System with OMNIFORM� Design. Directions for use. Allergan.
11. Dixon AFR et al. Laparoscopic adjustable gastric banding induces prolonged satiety: a randomized blind crossover study. J Clin Endocrinol Metab 2005. 90: 813-819.
12. O'Brien PE et al. treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med 2006. 144(9): 625-634.
13. Peeters A et al. Substantial intentional weight loss and mortality in the severely obese. Ann Surg 2007. 246: 1028-1033.
14. Colles SL et al. Hunger control and regular physical activity facilitate weight loss after laparoscopic adjustable gastric banding. Obes Surg 2008. 18: 833-840.