Curing Type 2 Diabetes With Bariatric Surgery?

I tried really hard to ignore the front page article in the New York Times on Wednesday, January 23, 2008, entitled “Diabetes Study Favors Surgery to Treat Obese,” and written by Denise Grady. And, I was doing well until this morning (Sunday, January 27, 2008) despite e-mails this week from patients of mine wondering if they should get gastric banding surgery, when I saw the following headline in the Columbia Daily Tribune: “Diabetes Cure Linked To Surgery”. I now feel an intense need to respond.

Background

Those of you have read my earlier postings about obesity and the links with type 2 diabetes already know that for most people, getting type 2 diabetes takes both obesity and the genes for type 2 diabetes- it’s opportunity and genetics at their best (or worst). Type 2 diabetes is, for most people a combination of insulin deficiency and insulin resistance. Obesity causes insulin resistance and this is often enough to “tip the balance” leading to expression of the diabetes, i.e., high blood sugar levels. We have known for many, many years that early in the course of type 2 diabetes, losing weight, no matter how it is done, often leads to remission of the diabetes, which may persist long-term, but only if the weight is not regained. We even know from an excellent study called the Diabetes Prevention Trial (or “DPP” as it is widlely known) that treating obese people who have mildly abnormal blood sugar levels with diet and exercise that leads to weight loss, can greatly decrease the rate at which such people develop full-blown diabetes. Are you with me so far?

Bariatric Surgery For Obesity/Diabetes

As I discussed in earlier postings, bariatric surgery (bariatric is from the Greek work “baros,” meaning weight) is a well-accepted approach to treating severe forms of obesity that are unresponsive to medical therapies (e.g, diet, exercise). Despite the high costs and complications, for people with severe obesity, the complications of the obesity often make the surgery worthwhile. There are a number of studies worldwide that document the long-term benefits from bariatric surgery in selected patients. So now we have a report published in the Journal of the American Medical Association (JAMA) on January 23, 2008 suggesting that bariatric surgery might be the way to go in curing type 2 diabetes in its early stages.

What Did The Article Show?

The study was performed by a research team at Monash University in Melbourne, Australia. The lead author was John Dixon. Dr. Dixon and colleagues studied 60 patients with recently-diagnosed type 2 diabetes who were obese (BMIs 30-40). The investigators randomly assigned patients to either bariatric surgery (with a gastric banding procedure) or traditional treatment for the diabetes (diet, exercise, medications, etc.). They found that after 2 years, the surgery group had complete remission of the diabetes in 73% vs. only 13% in the non-surgery treatment group. The authors concluded that bariatric surgery was an effective alternative to the usual approach to treating type 2 diabetes. The authors predicted that bariatric surgery would be used more and more in the future to treat diabetes.

Is This News Or No News?

There is a National Public Radio show called “Wait, Wait Don’t Tell Me,” which is basically a quiz show on current events. In one segment of the show the host asks the guest panel members to decide if a piece of recent news is, in fact news or no news (i.e., a big deal or nothing exciting). So, let’s pretend I am on that guest panel and the host asks if the bariatric surgery study summarized above is news or no news. What would I say? I would say “no news.” Why? First, I would point out that the surgery, not surprisingly, was associated with striking weight loss compared to the non-surgery group. No duh. I would also point out that the study was very short-term- two years total, far to short to really assess the long-term benefit of a surgical procedure that costs $15,000-$25,000 in the U.S. For example, in 10 years, how many of the surgical group patients have diabetes compared to the non-surgical group patients? How many of the surgical patients had developed complications from their surgeries? You get my drift? This small, short-term study should not be used as the basis for moving to bariatric surgery as the method of choice for treating diabetes in people with mild degrees of obesity (BMIs 30-35%, like a large percentage of those in the U.S. who do not have diabetes (at least not yet). Maybe someday we will need to accept the fact that surgery is the best way to treat all obesity, with or without diabetes. We are a long way from that someday.
The New York Times article was well written and explored the various issues I have raised. The article in my local newspaper was scary. The subject of the article was a local bariatric surgeon who is clearly hoping to greatly increase the number of bariatric surgery procedures he performs in people with type 2 diabetes. I would suggest that he go slow and curb his enthusiasm until we have much more data. Of course, he may find that many insurers, including Medicare, will not jump at the chance to help out the rapidly growing number of bariatric surgeons in the U.S.

A Plea

This is as much about obesity as it is about diabetes. I hope we have not given up on the possibility of controlling our national passions for food and inactivity through means other than surgery. I like surgeons and some of them are close friends of mine but I do not like the idea of surrendering the management of obesity/diabetes to the scalpel just yet.

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