Dr. Sylvia Weiner, MD is a leading expert in obesity and metabolic surgery. With nearly two decades of experience, she has established herself as a top specialist in the treatment of obesity and its consequences. Since October 2022, she has served as the Head of the Department of Obesity and Metabolic Surgery at the Sana Klinikum Offenbach. Dr. Weiner is also the driving force behind the Obesity Academy, an innovative institution in the Frankfurt-Rhine-Main metropolitan region dedicated entirely to the treatment and management of obesity. Together with Dr. Anne Freund, she offers a unique interdisciplinary program that provides patients with comprehensive support for weight loss and improved quality of life.
Dr. Weiner earned her medical degree from the University of Würzburg and completed her specialist training at renowned institutions such as Mount Sinai Hospital in New York City and Justus Liebig University in Giessen. Her solid education and many years of experience as department head at Sachsenhausen Hospital and the German Bariatric Center, as well as her role as head of the Department of Bariatric and Metabolic Surgery at Nordwest Hospital in Frankfurt am Main, have given her not only extensive expertise but also a leading position in the professional field.
With more than 100 scientific publications, she actively contributes to the advancement of obesity and metabolic surgery. Her broad range of treatments includes both conservative and surgical approaches. Dr. Weiner places great importance on personalized patient care, relying on a combination of nutritional counseling, physical therapy, medication, and behavioral therapy to achieve sustainable weight loss.
Dr. Weiner follows an interdisciplinary approach and works closely with physicians, nutritionists, physiotherapists, and psychologists to develop individualized treatment plans for each patient. In addition, her Obesity Academy offers extensive training and workshops for professionals to enhance the treatment of obesity throughout the medical community. Of particular note is Dr. Weiner’s commitment to research and the development of new treatment methods.
On the topic of diabetes surgery, the editorial team of the Leading Medicine Guide had the opportunity to speak with Dr. Weiner and gain insights into this still relatively unknown option for diabetes patients.
Diabetic surgery is an emerging field of medicine that deals with surgical procedures to treat diabetes mellitus, particularly in patients with type 2 diabetes who are unable to achieve adequate control of their blood glucose levels despite intensive drug treatment. Surgical procedures, which primarily include bariatric surgery such as gastric bypass and sleeve gastrectomy, have proven to be promising treatment options for sustainably improving the metabolic disorders associated with diabetes or even remitting the disease in some cases. This area of medicine aims not only to reduce body weight, but also to increase insulin sensitivity, normalize insulin production and reduce the risk of secondary diseases such as cardiovascular disease, kidney failure or blindness. In view of the increasing number of people with diabetes worldwide, diabetic surgery is becoming an increasingly important option in the treatment of this complex disease.
There are currently around 11 million people living with diabetes in Germany, including around 8.7 million with diagnosed type 2 diabetes, which accounts for 95 percent of all cases, and 372,000 with type 1 diabetes. (Source: German Diabetes Aid, https://www.diabetesde.org/ueber_diabetes/was_ist_diabetes_/diabetes_in_zahlen)
In addition, it is estimated that two million people are undiagnosed. More than half a million new cases occur every year, which corresponds to around 1,600 per day. The average age at which type 2 diabetes is diagnosed is 61 for men and 63 for women, with those affected often living with the disease undetected for as long as eight years. Around 340,000 adults and 32,000 children and adolescents under the age of 18 have type 1 diabetes. Every year there are around 3,100 new cases in children and adolescents and around 4,150 in adults. The number of type 1 diabetes cases is increasing by three to five percent each year. According to forecasts, the total number of diabetes cases in Germany will rise to around 12.3 million by 2040.
“Diabetes is part of the disease obesity. Of course, the sugar content in various foods also contributes to the significant increase in diabetes, as do the additives in industrially processed foods or light products. These have a significant impact on our gut microbiome and our metabolism, as the effect of the signaling chains is greatly altered. The body goes into a state of alarm because it registers the arrival of poorly utilizable substances. It tries to save energy and shuts down the metabolism. As a result, more sugar is stored in the fatty tissue and the liver produces additional sugar - in an effort to defend itself against this unspecific attack. This development takes place over many years and is not caused by the occasional consumption of light products or sugar alone. The body reacts in the long term to what it is regularly fed - and unfortunately this is often not very good. It's not just about sugar consumption, but about everything that changes the metabolism in the long term. Ultimately, the metabolism always tries to protect us from starvation,” Dr. Weiner explains and adds a special feature regarding resistance to diabetes:
“Natural birth and breastfeeding, for example, can reduce the risk of diabetes in both mother and child from the very beginning of life. This is because during natural birth, the baby comes into contact with the mother's vaginal flora, which promotes the development of a healthy microbiome. This plays an important role in metabolism and protects against type 2 diabetes in the long term. Breastfeeding also supports the baby's intestinal flora, provides important nutrients and hormones and reduces the risk of obesity and diabetes. Breastfeeding helps the mother to stabilize blood sugar levels, lose weight and improve insulin sensitivity, which also reduces the risk of diabetes”.
Surgical treatment of type 2 diabetes has established itself as a promising therapeutic option in recent years, particularly in obese patients for whom conservative treatments such as diets and medication are not sufficiently successful.
The most commonly used procedures include gastric bypass and sleeve gastrectomy, which can lead to a significant improvement in blood sugar control. “Gastric bypass is considered an efficient, proven procedure and is also recommended as a surgical therapy in international guidelines, as the operation bypasses the first part of the small intestine. We know that certain messenger substances are produced in this area that have a positive effect on the pancreas. In principle, all procedures that lead to weight loss are positive. This is because there is an indirect positive influence through weight loss, the reduction of the fat content in the body and thus a secondary improvement in insulin resistance,” explains Dr. Weiner.
During the bypass operation, the stomach is divided into two parts: a small stomach pouch, which serves as a new, greatly reduced stomach, and the remaining, larger part of the stomach, which is largely excluded from the digestive process. The small intestine is rerouted so that the food passage skips the first part of the small intestine (duodenum) and part of the middle small intestine. This reduces the surface area over which nutrients and calories can be absorbed (malabsorption). This bypass effect leads to several positive effects: First, by reducing the size of the stomach, the amount of food that can be absorbed is greatly reduced. Secondly, bypassing the first section of the small intestine has specific hormonal effects. Studies show that this increases the release of hormones such as GLP-1 (glucagon-like peptide-1). These hormones regulate the feeling of hunger and the insulin effect and thus not only contribute to weight loss, but can also sustainably improve type 2 diabetes or even bring it into remission. The elimination of the first part of the small intestine therefore plays a central role, as this section is normally crucial for the absorption of calories and nutrients, especially fats and carbohydrates.
GP1 analog therapy is available as an alternative to surgery.
This uses medication that mimics the hormone GLP-1 (glucagon-like peptide-1). This hormone is released in the intestine after eating and regulates blood sugar and the feeling of hunger. GLP-1 analogs are mainly used to treat type 2 diabetes and in some cases for weight loss. They work by promoting the release of insulin when blood sugar is high, while reducing the release of glucagon - a hormone that increases blood sugar. This keeps blood sugar levels stable. They also delay gastric emptying, which makes you feel fuller for longer, and act directly on the brain to reduce appetite. These medications are usually administered as an injection, often once a day or once a week, and have proven to be an effective and safe therapy for both blood sugar control and weight loss. Side effects such as nausea are more common at the beginning of treatment, but often subside over time.
“However, GP1 analogue therapy only works as long as it is used,” emphasizes Dr. Weiner.
The sleeve gastrectomy is a slightly less complex method in which a large part of the stomach is removed, leaving only a tube-shaped remnant. This operation significantly reduces food intake and at the same time reduces the production of ghrelin, the so-called hunger hormone. Less ghrelin means that the patient feels less hungry, which leads to spontaneous weight loss. In addition to this mechanical effect, the procedure also has positive effects on insulin sensitivity and blood sugar levels.
“When it comes to deciding on a treatment method, there is always a primary medical recommendation. Ultimately, however, the patient decides for themselves whether they want an operation at all, as we are still in the elective area here. Unfortunately, we often fail to gain the patient's and/or GP's understanding for an operation, even though diabetes is no longer detectable after such an intervention and insulin therapy can be suspended for a period of around 5 to 15 years. Patients also benefit from long-term survival, as a later occurrence of long-term damage can be significantly prevented by delaying diabetic disease,” explains Dr. Weiner.
With regard to insulin intake, it is often the case that patients experience a significant reduction or even an immediate and complete cessation of insulin therapy after successful diabetic surgery.
“The effect of the operation is stronger the shorter the patient has had diabetes. So anyone who has been injecting insulin for 20 years or longer should not expect such strong effects. However, there are patients who had to be treated with 200-300 units of insulin before the operation and no longer needed insulin immediately afterwards - a condition that often persists for many years. Weight loss then occurs over the course of the operation and the patient loses around 80% of their excess weight in the first six months,” explains Dr. Weiner, explaining why more patients are not taking advantage of diabetic surgery:
“This therapy is not entirely new. It has been included in the international statements of the diabetes societies for almost ten years. However, this knowledge is only insufficiently disseminated among general practitioners. Unfortunately, only a few patients are aware of the benefits of surgery, which is why there has not yet been a huge rush of patients. Education is urgently needed here, because ultimately surgery in these cases is far less dangerous than taking insulin continuously - especially with regard to secondary cardiovascular diseases such as heart attacks or strokes. These 'side effects' usually only occur after 20 years of taking insulin. Patients are often unaware that they may be losing years of life”.
Lifestyle changes and post-operative care play a crucial role in the long-term success of surgical interventions for the treatment of type 2 diabetes.
“Important for long-term success is the elimination of the duodenum through classic bypass surgery, which favors the approximately 15 years of insulin-free therapy. However, it must also be taken into account that the diabetes may return in case of doubt. After an operation, there is a transitional phase of around one to three months during which the patient's diet is rebuilt, as they have to get used to their new eating and lifestyle habits. Basically, patients should take additional multivitamins for the rest of their lives because the reduced stomach can no longer absorb enough vitamins. Long-term monitoring of sugar levels is also advisable,” explains Dr. Weiner.
Sustained weight loss, especially in the first few months after surgery, contributes significantly to improving insulin sensitivity and blood glucose regulation. Patients therefore need to make long-term changes to their eating habits by being more calorie-conscious, eating a balanced diet and consulting nutritionists or dieticians if necessary. Exercise is another important lifestyle component that has a positive effect on blood sugar control. Regular physical activity increases insulin sensitivity, improves metabolism and helps to lose or stabilize excess weight.
Diabetic surgery is available to patients of all health insurance companies, provided the disease is recognized as such, and is one of the so-called standard services provided by health insurance companies.
Insulin-free through the Obesity Academy
Surgical interventions for type 2 diabetes offer considerable economic benefits in the long term. The improvement in blood sugar control and possible remission reduces the need for expensive diabetes medication and insulin. In addition, complications such as cardiovascular disease or kidney failure are reduced, which lowers healthcare costs and absenteeism. The savings in medication and treatment costs often exceed the initial investment in surgery, making it a cost-effective therapy.
“Around 30% of our patients are those who have had diabetic surgery, mostly in the 40 or so age group, although there is no set age limit. For example, we recently had a 76-year-old patient who also benefited, simply because of the improvement in his quality of life in everyday life, as he no longer has to constantly handle insulin and monitor his values. This doesn't get any easier in old age. The older patient also benefits in terms of lifespan, as long-term insulin use increases the risk of becoming a dialysis patient,” explains Dr. Weiner at the end of the discussion.
