T2D (Metabolic Surgery) — SCE Endocrinology MCQ

Correct answer: B — Consider metabolic surgery in BMI ≥35 kg/m² when hyperglycemia is uncontrolled despite optimal therapy

Option B (Consider metabolic surgery in BMI ≥35 kg/m2 when hyperglycemia is uncontrolled despite optimal therapy) is correct because NICE guidance on obesity identifies BMI 35 kg/m2 or above with a significant obesity-related comorbidity, including type 2 diabetes, as the threshold for referral to a specialist weight management or bariatric surgery service. This patient has T2D and a BMI of 39 kg/m2, meeting that criterion, and surgery is offered as an adjunct once medical and lifestyle measures have failed to achieve glycaemic control. Metabolic surgery works through mechanisms beyond simple restriction, including altered gut hormone signalling (GLP-1, PYY) and improved insulin sensitivity, producing durable improvements in HbA1c, blood pressure and lipid profile in appropriately selected patients. It is not a universal cure and requires ongoing multidisciplinary follow-up, but current standards clearly support consideration of surgery at this BMI threshold in the context of uncontrolled diabetes. Why the other options are wrong: C. Not recommended for diabetes: Contradicts NICE, which explicitly recommends assessment for bariatric surgery in eligible patients with T2D, particularly those with recent-onset disease, as it improves glycaemic control and reduces comorbidity. D. Only BMI ≥50 kg/m2 qualifies: This vastly overstates the threshold; NICE sets eligibility at BMI 35 kg/m2 with comorbidity (or 30 kg/m2 for recent-onset T2D in some populations), not 50. E. Cures diabetes in all: Remission rates are high but not universal; outcomes depend on diabetes duration, beta-cell reserve and postoperative weight maintenance, so cure cannot be guaranteed. A. Contraindicated in CKD: CKD is not a blanket contraindication; many patients with CKD benefit from metabolic surgery, with careful perioperative and nutritional monitoring rather than exclusion. Key point: In the UK, BMI ≥35 kg/m2 with poorly controlled type 2 diabetes despite optimal medical therapy meets NICE criteria for referral for bariatric surgery assessment.

Reference: NICE Quality Standard QS127, Obesity: clinical assessment and management, Quality statement 4 (referring adults with type 2 diabetes for bariatric surgery assessment), https://www.nice.org.uk/guidance/qs127/chapter/quality-statement-4-referring-adults-with-type-2-diabetes-for-bariatric-surgery-assessment