Are diabetologists against metabolic surgery?

Since 2022, the French Haute Autorité de Santé (HAS) has allowed metabolic surgery for patients with uncontrolled type 2 diabetes and a body mass index (BMI) between 30 and 34.9 kg/m². The main objective of this study was to identify the characteristics of patients to whom diabetologists propose metabolic surgery.

This was a single-center, prospective study including patients with diabetes and a BMI between 30 and 34.9 kg/m², conducted between January 2024 and March 2025. A questionnaire was completed by diabetologists, including information on diabetes, comorbidities, and a physician-rated adherence out of 10. The physician then indicated whether metabolic surgery was proposed to the patient.

Data from 72 patients were collected. Twenty-six (36.1%) were women; the mean age was 50.0 years and the mean BMI was 32.2 kg/m². The mean duration of diabetes was 6.9 years and the mean HbA1c was 7.7%. The mean number of antidiabetic treatments was 2.8, and 49/72 (68.1%) patients were treated with insulin. Metabolic surgery was proposed to 25 patients (34.7%). Surgery was considered for patients with higher HbA1c (8.6 vs. 7.2%, p < 1 × 10⁻⁴), a longer duration of diabetes (9.0 vs. 5.8 years, p = 0.02), more antidiabetic treatments (3.6 vs. 2.4, p < 1 × 10⁻⁴), and more often for patients receiving insulin (96.0% vs. 53.2%, p < 1 × 10⁻⁴). There was no significant difference in age, BMI, sex, or physician-rated adherence score between patients to whom surgery was proposed and those to whom it was not.

Metabolic surgery was preferentially proposed to patients with more advanced diabetes, in accordance with current recommendations. However, patient acceptance remained very low, highlighting a major barrier to implementation.