Is Diabetes Surgery Ready For Prime Time?
Monday, March 15, 2010
Although, in the end I spent less than 24 hrs in the Emirates, one of the highlights of attending the 1st International Abu Dhabi Diabetes Conference, was the opportunity to once again hear David Cummings (Seattle) speak about how bariatric surgery can lead to the remission of type 2 diabetes. Cummings’ talk certainly provided plenty of food for thought on my long flight back to Canada.
As outlined in a newly released Diabetes Surgery Position Statement published in the latest issue of the Annals of Surgery, surgical approaches may well prove to be the treatment of choice in carefully selected patients with poorly controlled type 2 diabetes and a BMI greater than 30.
While the authors of the Statement emphasize the need for more clinical trials to investigate the future role of surgery in diabetes treatment, they also call for further investigations on the mechanisms of surgical control of diabetes (which are far from being fully understood).
Although weight loss itself clearly plays a significant role in the reversal of diabetes generally seen with bariatric surgery, with gastric bypass surgery, this reversal of diabetes often precedes the weight loss and there are likely neuroendocrine consequences to allowing food to bypass the duodenum that may substantially affect glucose metabolism (including regeneration of pancreatic beta-cells).
Thus, a better understanding of exactly how gastrointestinal surgery “cures” diabetes, will hopefully also open new avenues for pharmacological treatments that can mimic the effects of surgery in these patients.
Indeed, certain gut-hormones, which are known to be dramatically affected by gastric bypass surgery (e.g. GLP-1), have already been shown to have a beneficial effect both on diabetes and weight management (e.g. liraglutide).
Health professionals who want to learn more about this topic should consider attending the upcoming First Canadian Summit Metabolic Surgery for Type 2 Diabetes to be held in partnership with the Canadian Obesity Network and the Canadian Diabetes Association at the Hôtel Le Centre Sheraton, Montréal, May 6-7, 2010.
To watch a recent episode of 60 Minutes on CBS, which features interviews with Cummings and others discussing the surgical approach to type 2 diabetes, click here.
Very much appreciate hearing from my readers on their thoughts regarding whether or not diabetes surgery (vs. lifelong medications or injections) will significantly change how we treat diabetes in the future.
AMS
Edmonton, Alberta
Monday, March 15, 2010
Again I feel like research and the resulting evidence are bypassing the problem just like gastric bypass bypasses digestion. Should we not also invest in prevention through weight management, exercise as medicine and nutrition education?
Case Study:
I have a 71 year old male patient that I recently re-evaluated who was diagnosed with Diabetes Type II 7 years ago. Since that time, he has been effectively managing his A1C through a novel method of eAG that we incorporated several years ago in our clinics and our program of exercise. (eAG takes multiple sugar readings and averages them and converts them to an A1C reading) This is a better method of training and educating type II’s to understand sugar and insulin. Aside from food management (noteably the most important component in type II progression), we placed him in structured exercise program twice per week for one hour that includes both strength training of major muscle groups and cardiovasular training, along with weight management counceling and education in nutrition once per month for 45 minutes. Although his doctor would not consider him free of Diabetes, his blood sugars have remained below the 100 mg/dl markers and his disease has not progressed. In addition, these treatments have helped to manage his weight, reduced his risk of injury in his daily activity, reduced his overall risk of stroke and heart failure, improved his blood pressure and triglicerides and he no longer complains of back pain. (to see more on eAG go to professional.diabetes.org/eAG)
I think regular exercise can provide a remarkable change in the profile of disease prevention and management. It requires the kind of funding and commitment that drugs and surgery enjoy.
Monday, March 15, 2010
Thanks for posting on this issue. More and more good evidence suggests that bariatric surgery is an effective tool for treating diabetes. Although I share the opinion that we should continue to investigate mechanisms, I also think we should do a better job of determining 1) who are the best candidates for surgery, 2) how to better monitor and provide longterm support to patients who undergo surgery, 3) how to improve intensive lifestyle interventions so we can see even better outcomes. As surgery becomes more and more popular, I am certain we will see more adverse outcomes such as nutritional deficiencies, weight regain, and other problems that occur primarily because of the low follow-up and lack of education in both patients and practitioners.
Monday, March 15, 2010
Mavis< Should we not also invest in prevention through weight management, exercise as medicine and nutrition education?>
Unfortunately, thus far the investments in prevention, exercise and nutrition have not produced lasting results (with the exceptions of the anecdotal cases you mention). As I noted in my posting, no one is suggesting that surgery should be the primary approach for any patient with type 2 diabetes, rather, this should be the strategy in selected patients.
I agree that there should be more funding to support exercise interventions in general.
AMS
Monday, March 15, 2010
Has anyone ever done a study to confirm that these changes after weight loss surgery are a result of the surgery itself and not of the the diet followed by the patient after the surgery?
Monday, March 15, 2010
Beth
As mentioned in the post, the weight loss itself certainly plays a major role in the remission of type 2 diabetes and of course, dietary weight loss will also lead to remarkable improvements in glucose control. The problem of course is that very few people can sustain the caloric restrictions induced by surgery without surgery (which is the whole point of doing surgery in the first place).
AMS
Tuesday, March 16, 2010
Thanks for the response. I was speaking to the reports that I’ve read other places as well that diabetes is reversed after WLS well before weight loss occurs. I just wonder if it’s been determined how much of that is related to the surgery itself and how much is related to the drastic change in diet. I also wonder whether diabetics with WLS will have similar recidivism issues.
Tuesday, March 16, 2010
Beth: just to be clear, one does see reversal of diabetes even with dietary weight loss (e.g. with OPTIFAST) or with gastric banding, which does not change the passage of food through the gut. But in these cases, the improvement in diabetes takes longer and is proportional to the amount of weight lost. In contrast, the resolution of diabetes with bypass surgery is much faster and there is no direct link between weight loss and resolution.
Of course, the diets change after surgery and this may well also have an effect.
With regards to recidivism, the risk for this is far smaller with bariatric surgery than with lifestyle change alone, but of course, when surgery fails, the diabetes is likely to come back.
AMS