Thousands of patients with type 2 diabetes are being denied the chance of life-saving surgery because they do not fit strict NHS guidelines on weight.
Around 3.6m people in the UK suffer from type 2 diabetes, which costs the NHS up to £10bn a year to treat.
A leading bariatric surgeon told Inside Out surgery was "the closest thing to a cure" and should be used more often.
Only type 2 patients with a BMI over 30 are currently eligible under obesity guidelines.
At least 15% of sufferers are of normal weight and therefore don't qualify for operations like gastric bypasses on the NHS.
Of those who do meet the criteria - less than 1% access surgery.
The Chair of Bariatric and Metabolic Surgery at Kings College, Professor Francesco Rubino, has been researching the effects of bariatric surgery on type 2 diabetes for 15 years.
"I don't think this is seen as a lifesaving operation as it is," he told the BBC.
"The biggest barrier we have is primarily one of stigma against obesity. The vast majority of the public believes this is a cosmetic intervention and unfortunately many physicians think the same way."
Professor Rubino said operations involving the manipulation of the stomach or intestine do not just help people lose weight - they also alter hormones in the gut, which in turn influences insulin production.
"More than 50% of people with type 2 diabetes can enjoy long term remission. Another 30 or 40% enjoy a major improvement," he added.
How does it work?
Media captionThis video explains how a gastric bypass is carried out
Bariatric surgery refers to a set of operations carried out with the primary intention of helping people who are morbidly obese lose weight.
The two most common types of weight loss surgery are:
Gastric band, where a band is used to reduce the size of the stomach so a smaller amount of food is required to make someone feel full.
Gastric bypass, where the digestive system is re-routed past most of the stomach so less food is digested to make someone feel full.
Professor Rubino said the use of bariatric surgery was currently "shaped around weight loss", with remission from diabetes seen as a by-product.
Instead, he said, it should be offered as a "standard treatment" for type 2 patients, who are not responding to dietary or pharmaceutical intervention, regardless of BMI.
He wants to see guidelines from the National Institute for Health Care and Excellence (NICE) updated to reflect this.
"Diabetes care practitioners don't use BMI to decide whether you go on one medication or another. So why should surgery be regulated by a parameter that is foreign to the management of diabetes?
"In patients who have done everything possible - what is the point of not offering it, just because their BMI does not fit the criteria that we have arbitrarily introduced for the treatment of obesity?"
Professor Rubino said type 2 diabetes was often "dismissed as something that can be easily managed through diet and exercise".
"When diabetes is fully developed it becomes a serious disease and many patients - 50% or more - are not able to control it, no matter how many medications they take," he added.
He said each bariatric operation costs £6,000, making it "one of the most cost effective interventions in medicine at the moment".
Image caption Barbara Gratton from Yorkshire has normal blood sugar levels post surgery
Barbara Gratton, 53, suffered with type 2 Diabetes for nearly 20 years.
It was caused by a genetic disorder called Familial Partial Lipodystrophy, which prevents her body from properly storing fat and caused her pancreas to malfunction.
Mrs Gratton's low weight meant she did not quality for bariatric surgery under the current obesity guidelines set by NICE.
"My systems had become resistant to any kind of medication. So I was looking at the co-morbidities - heart failure, stroke, blindness," she said.
Mrs Gratton was so worried about her future she signed up to Dignitas, an assisted suicide organisation.
Diabetes is a condition that causes a person's blood sugar to become too high.
Type 1 can develop at any age, but often begins in childhood. It is not related to diet or lifestyle.
Type 2 is far more common. It is usually seen in adults and can be associated with obesity. It can lead to serious complications, including kidney failure, blindness and heart disease.
It's the most common cause of vision loss and blindness in people of working age.
After a two year battle with "NHS bureaucracy" she was eventually offered surgery - but at that point she had already signed up for private treatment under Professor Rubino.
She underwent a bypass operation at Kings College Hospital on 5 September and within days she was off the insulin needed to control her blood sugar levels.
"It allows me to have a normal life, even with my underlying condition.
"If you have type 2 diabetes at these lower BMIs - £6,000 will get it done and reduce liver cancer and strokes."
Some 6,000 bariatric operations are carried out in the UK every year. Around a quarter of these patients have type 2 diabetes.
Image caption Mr Benge's diabetes was impacting his quality of life and making him depressed
Britain lags behind other European countries, where around 50,000 bariatric operations are carried out every year.
Even those who fall within the weight parameters set by NICE can struggle to gain access on the NHS.
David Benge, 56, from Hastings, recently had gastric bypass at Kings. He was initially told he was not "big enough" despite having a BMI of 36.
"From GP level they were saying it's not enough for us to refer you," he said.
"So there was a bit of pushing... at the time to get me referred, which they did in the end."
Mr Benge's blood sugar levels also dropped dramatically in the days after surgery.
Director of the Centre for Guidelines at NICE, Professor Mark Baker, said there might be scope to extend obesity and diabetes' guidelines in the future.
"There is very little doubt that people with type 2 diabetes - and at any level of weight - can see their glucose control improved by bypass surgery," he added.
"It is an effective treatment and we'd like it to be more widely available. But there are other priorities in diabetes and there is a limited budget."
An NHS England spokesperson said: "Bariatric surgery should only be considered for severe obesity where other approaches have not been successful."
Published 27/06/2016 | 02:30
5Wicklow Rose Jane Harrison lost 13 stone after gastric band surgery
Jane Harrison will compete in this year's Rose of Tralee. Photo: Colin O'Riordan.
Wicklow Rose Jane Harrison (26) had battled with her weight most of her life. In February 2011, however, aged 21 and weighing 23 stone, she had gastric band surgery to assist her weight-loss.
"I feel like there is a huge stigma to weight-loss surgery. It is something that scares me to talk about, but at the same time I would like people to know that it is definitely not the easy way out," Jane says.
"I remember lying there in pain thinking I would never put myself through it again. It is definitely a wake-up call. There are thousands of people getting it done every year and many people are afraid to say it, in case they might be looked at as cheaters almost.
"It was the hardest route I have tried and I tried them all; I tried liquid diets, I tried dietitians, everything."
55Jane Harrison before her gastric band surgery.
Jane's weight began to decrease rapidly in the year-and-a-half that followed her surgery, but her mindset remained the same, causing her self-esteem to plummet even further.
"At that point I still had not dealt with the real problems that had led to my weight gain," Jane explains. "So I lost 13 stone, but had yet to acknowledge that the overeating and the unhealthy lifestyle were caused by my self-esteem issues.
"I lost the weight and then became obsessed with trying to maintain it; I was going to external people and things to get my happiness because overeating was no longer an option for me.
"You just turn those destructive habits to something else unless you really deal with it," Jane adds. "I felt so defeated when I managed to get down to 10 stone at one point and would go out and get a few compliments, but I would go home and still feel empty."
Over time, Jane learned to address the self-esteem issues she had developed in childhood: "From the age of 12 I was going to nutritionists and child dietitians. So my weight was an issue throughout my entire childhood."
"My parents were my backbone growing up and they knew I just couldn't get my overeating under control even throughout my teens and they helped me try every angle.
55Wicklow Rose Jane Harrison lost 13 stone after gastric band surgery
"I went on a liquid diet once for 16 weeks and I lost about four stone in six weeks, but I put it back on in double, everything was just short term because there was something not right underneath it all.
"From about maybe 13, when you start going out to discos and everybody is wearing fab clothes that you cannot, that is when you start to realise 'well maybe I am a bit different,' but I have always had the best group of friends and family around me so I was never bullied as such, but you would hear comments and jabs."
Being overweight for such a long period left Jane feeling like she was still the overweight person in every room.
"I lost quite a lot of the weight following the surgery, but I found that I just wasn't that happy still," Jane explains. "I thought that someday, I was just going to wake up at my goal weight and be a happier person. I thought the weight and the taunting was the problem, but it wasn't, the issue was the way I looked at myself; after years of being overweight, I just didn't feel like I was worth anything and I felt as if I still needed approval from people."
Happily, Jane has now learned to care less about what others think. "It's not that I don't care anymore - because everyone cares to a certain extent about what other people think of them - but I don't let it get to me anymore," she says. "I know that I am not going to be everyone's piece of cake, but what I have realised over time is that nobody is; you cannot please everyone.
"When you are overweight for so long you think weight loss is the answer to everything," Jane says.
"I was always living for the 'when' so 'when I lose a bit more weight I will do this or that,' but now I am at a stage where I don't put things off.
"I could have said 'I will lose three stone and I will apply for the Rose of Tralee next year,' but why? What is the difference? One very important thing I have learned is to try and accept who you are while you are losing weight because I did not, and I hit a low as a result of that."
Over time, Jane's mind has thankfully caught up with her body.
55Wicklow Rose Jane Harrison lost 13 stone after gastric band surgery
"It took some big realisations and I definitely had to get in touch with myself a lot more. I got into spirituality and meditation and began to just work out what I want in life," Jane explains. "Now I know my triggers and when I've disconnected from the path I am on and I know how to get back on it."
Jane, who put off going to college after school because of her low self-esteem, is now enrolled on a college course in Communications and will represent Wicklow in the 2016 Rose of Tralee.
"I have decided to go for things I want now and not hold myself back and that is a huge part of why I entered the Rose of Tralee. I am definitely not at my dream weight and there are 100 things I would like to change about my figure, and I will still go to the gym and attempt to, but it doesn't consume me anymore like it did a few years ago," she says.
"When I go down to Tralee, it is going to be two weeks of food and drink and that doesn't freak me out at all, whereas two years ago the prospect of not having complete control over what I am eating would have really freaked me out," Jane admits. "I have a healthy approach to food and exercise now and I know what foods I can have and what I cannot have; I think when you just realise you want to be happy for yourself rather than others, that is when everything really clicks into place
He said that the long-term results from LABG had been achieved without any significant technological innovation of the device in the last 20 years
"Low BMI patients are a target population that as metabolic surgeons we need to take care of to prevent future morbid obese patients"
Thursday, September 15, 2016 - 09:21
Owen Haskins - Editor in chief, Bariatric News
Patients who have a BMI30.0-34.0 (class 1) and who are suffering from a significant obesity-related health burden should be offered bariatric surgery, according to Luigi Angrisani, S Giovanni Bosco Hospital, Naples, Italy. In his presentation, ‘Low BMI patients: a target population to take care of to prevent future morbid obese patients, he cited a 2014 a Position Statement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) (Obesity Surgery. Bariatric Surgery in Class I Obesity – A Position Statement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) 2014), which states:“A clinical decision should be based on a more comprehensive evaluation of the patient’s current global health and on a more reliable prediction of future morbidity and mortality.”
Angrisani added that such a decision should take into account “more than just a patient’s BMI.”
He said that there an array of intragastric balloons (eg.Heliosphere Bag, Reshape Dual-balloon, Orbera, Spatz Adjustable Balloon System) and endoluminal procedures (eg. Apollo Overstitch, POSE and Endobarrier) that have shown weight loss in the short-term however, these devices/procedures have not yet proved long-term efficacy.
In comparison, the LAGB procedure has demonstrated long-term efficacy. Angrisani explained that in his own centre, between January 1996 and December 2015 they have carried out 107 bariatric procedures on obese patients with BMI≤35, and 32 patients received a LAGB. The ten year outcomes from these patients revealed on average patients lost 14kgs and the BMI was reduced from 33.78 to 29.6, with 40.2 average %EWL. Moreover, only three patients (9.3%) had their band removed.
He said that the long-term results from LABG had been achieved without any significant technological innovation of the device in the last 20 years (design, profile, material) or with little evolution of our knowledge in the last 15 years, such as the ability to calculate the ‘neo-pylorus’ diameter at time of band adjustment.
“Despite this lack of knowledge, the LAGB still remains an effective procedure and has demonstrated a high efficacy in low BMI and adolescents patients,” he concluded. “The LAGB has several advantages compared to more invasive procedures such as the absence of mortality and malnutrition, with no need for vitamin supplementation. Low BMI patients are a target population that as metabolic surgeons we need to take care of to prevent future morbid obese patients.”