Type 2 Diabetes May Be Caused by Intestinal Dysfunction

This press release is an announcement submitted by New York-Presbyterian Hospital/Weill Cornell Medical Center/Weill Cornell Medical College, and was not written by Diabetes Health.

Mar 13, 2008

NEW YORK – Growing evidence shows that surgery may effectively cure type 2 diabetes – an approach that not only may change the way the disease is treated, but that introduces a new way of thinking about diabetes.

A new article, published in a special supplement to the February issue of Diabetes Care by a leading expert in the emerging field of diabetes surgery, points to the small bowel as the possible site of critical mechanisms for the development of diabetes.


The study’s author, Dr. Francesco Rubino of New York-Presbyterian Hospital/Weill Cornell Medical Center, presents scientific evidence on the mechanisms of diabetes control after surgery. Clinical studies have shown that procedures that simply restrict the stomach’s size (i.e., gastric banding) improve diabetes only by inducing massive weight loss.


By studying diabetes in animals, Dr. Rubino was the first to provide scientific evidence that gastrointestinal bypass operations involving rerouting the gastrointestinal tract (i.e., gastric bypass) can cause diabetes remission independently of any weight loss, even in subjects who are not obese.


“By answering the question of how diabetes surgery works, we may be answering the question of how diabetes itself works,” says Dr. Rubino, who is a professor in the Department of Surgery at Weill Cornell Medical College and chief of gastrointestinal metabolic surgery at New York-Presbyterian/Weill Cornell.


Focus on the Upper Intestine


Dr. Rubino’s prior research has shown that the primary mechanisms by which gastrointestinal bypass procedures control diabetes specifically rely on the bypass of the upper small intestine – the duodenum and jejunum. This is a key finding that may point to the origins of diabetes.


“When we bypass the duodenum and jejunum, we are bypassing what may be the source of the problem,” says Dr. Rubino, who is heading up NewYork-Presbyterian/Weill Cornell's Diabetes Surgery Center.


In fact, it has become increasingly evident that the gastrointestinal tract plays an important role in energy regulation, and that many gut hormones are involved in the regulation of sugar metabolism. “It should not surprise anyone that surgically altering the bowel’s anatomy affects the mechanisms that regulate blood sugar levels, eventually influencing diabetes,” Dr. Rubino says.


While other gastrointestinal operations may cure diabetes as an effect of changes that improve blood sugar levels, Dr. Rubino’s research findings in animals show that procedures based on a bypass of the upper intestine may work instead by reversing abnormalities of blood glucose regulation.


In fact, bypass of the upper small intestine does not improve the ability of the body to regulate blood sugar levels. “When performed in subjects who are not diabetic, the bypass of the upper intestine may even impair the mechanisms that regulate blood levels of glucose,” says Dr. Rubino. In striking contrast, when nutrients’ passage is diverted from the upper intestine of diabetic patients, diabetes resolves.


This, he explains, implies that the upper intestine of diabetic patients may be the site where an abnormal signal is produced, causing, or at least favoring, the development of the disease.


A Theoretical Explanation


How exactly the upper intestine is dysfunctional remains to be seen. Dr. Rubino proposes an original explanation known in the scientific community as the “anti-incretin theory.”


Incretins are gastrointestinal hormones, produced in response to the transit of nutrients, that boost insulin production. Because an excess of insulin can determine hypoglycemia – a life-threatening condition – Dr. Rubino speculates that the body has a counter-regulatory mechanism (or “anti-incretin” mechanism), activated by the same passage of nutrients through the upper intestine. The latter mechanism would act to decrease both the secretion and the action of insulin.


“In healthy patients, a correct balance between incretin and anti-incretin factors maintains normal excursions of sugar levels in the bloodstream,” he explains. “In some individuals, the duodenum and jejunum may be producing too much of this anti-incretin, thereby reducing insulin secretion and blocking the action of insulin, ultimately resulting in type 2 diabetes.”


Indeed, in type 2 diabetes, cells are resistant to the action of insulin and the pancreas is unable to produce enough insulin to overcome the resistance.


After gastrointestinal bypass procedures, the exclusion of the upper small intestine from the transit of nutrients may offset the abnormal production of anti-incretin, thereby resulting in remission of diabetes.


A Call for Research


In order to better understand these mechanisms, and help make the potential benefits of diabetes surgery more widely available, Dr. Rubino calls for prioritizing research in diabetes surgery. “Further research on the exact molecular mechanisms of diabetes, surgical control of diabetes and the role played by the bowel in the disease may bring us closer to the cause of diabetes.”


Today, most patients with diabetes are not offered a surgical option, and bariatric surgery is recommended only for those with severe obesity – a body mass index (BMI) of greater than 35.


“It has become clear, however, that BMI cut-offs can no longer be used to determine who is an ideal candidate for surgical treatment of diabetes,” says Dr. Rubino.


“There is, in fact, growing evidence that diabetes surgery can be effective even for patients who are only slightly obese or just overweight. Clinical trials in this field are therefore a priority as they allow us to compare diabetes surgery to other treatment options in the attempt to understand when the benefits of surgery outweigh its risks. Clinical guidelines for diabetes surgery will certainly be different from those for bariatric surgery, and should not be based only on BMI levels,” he notes.


“The lesson we have learned with diabetes surgery is that diabetes is not always a chronic and relentless disease, where the only possible treatment goal is just the control of hyperglycemia and minimization of the risk of complications. Gastrointestinal surgery offers the possibility of complete disease remission. This is a major shift in the way we consider treatment goals for diabetes. It is unprecedented in the history of the disease,” adds Dr. Rubino.


Type 2 diabetes accounts for 90 to 95 percent of all cases of diabetes, and is a growing epidemic that afflicts more than 200 million people worldwide.

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Posted by Anonymous on 14 March 2008

I still don't think I want any kind of surgery to rearrange my innards.

Posted by Anonymous on 14 March 2008

dear sir
you know when old diabetics admitted in hospitals, it is needed they receive less insulin as they intake is lessen for fasting and several procedures that needs empty gastric and lessening of appetite. Also I think they need less tranquilizers as they can not preserve their imbalance well in new place and condition. But sorrily I see many endocrinologists who beleive tight control of BS in theses cituations and also I have seen many arrythmias in IHD patients due to hypoglycemia. thanks

Posted by Anonymous on 14 March 2008

in type 2 DM you know we have high glucagon level, on the other hand increase of enteroglucagon is culprit of bowel dysfunction in DM. Is incease of enteroglucagon is induces high serum glucagon level or it is secreted by pancreas? thanks

Posted by Anonymous on 15 March 2008

This report is scientific hoo--ha in my opinion,
just another way for Doctors to make money.
I know of people who have died from gastric bypass surgery and others who have gained the weight back. No matter what you do, the body can find a way to gain the weight back.

Posted by Anonymous on 15 March 2008

This is an interesting article as I've had Crohn's Disease for 24 years and Type 2 Diabetes for 3 years. Both being autoimmune diseases with a connection to the bowel would make interesting research.

Posted by Anonymous on 19 March 2008

This is a fantastic new way of looking at diabetes...I look forward to following Dr. Rubino's research. The results sound very promising!!!

Posted by Anonymous on 25 March 2008

there is no hoo haa at cornell weill it is one of the most respected in the world..

Posted by Anonymous on 25 March 2008

its funny how the medical community always misses the obvious things which are right under their nose. it is common sense to check mechanics first, and not blame nutrition. it is like blaming your gasoline when your injectors are clogging up because the injectors themselves are faulty.

Posted by Anonymous on 31 March 2008

I agree with the hoo-ha comment. My wife had gastric bypass surgery last year. The first thing you have to do to prepare for surgery is lose 10% of your weight. Then after the surgery, you are put on a low carb, low fat diet for life. That is why the Type 2 diabetes goes away. It is diet related, not surgery related. I'm a Type 2 diabetic. I went low carb as well, lost 30 lbs, and no longer take insulin shots. Nothing magical, just sound science and nutrition.

Posted by Anonymous on 7 April 2008

Not so fast. I represent physicians and I was told several years ago by a physician client who had stomach cancer/surgery that the surgery itself disrupted his appetite. I thought it was just interesting until the latest findings as to remission of diabetis from stomach surgery, including lap band. In fact two groups of diabetics underwent the same wt loss, but only the lapband/bypass group had remission. It does (obviously) have something to do with the surgical insult to the GI tract. This is an interesting theory as to the location of the dysfunction. I still wonder why the lapband has 85% remission. I don't think it is diet alone. My buddy had lapband and the Dr only "adjusts it" (ie, manipulates the band and thus the stomach) if he hasn't lost much wt or is still hungry. This manipulation (according to my friend ) can be EITHER tightening or loosening the band. Interesting-keep researching it !

Posted by Anonymous on 13 April 2008

I have been a diabetic for 24 yrs. I have tried to lose weight but I can't know matter what there is out there. I can't have any surgery bcause of my blood sugar to high. So I guess I just have to live with it because I'm to old to even think of surgery of any kind.

Posted by Anonymous on 21 April 2008

Ive read that the type 2 diabetes will disappear after the surgery, but before the weight is lost..Very interesting indeed

Posted by Anonymous on 19 July 2008

I would like to be updated on any clinical progress since it was first published.

Posted by Anonymous on 15 September 2008

First I would like to comment on the "hoo haa" blog..are you from another planet or are you not aware of NY Presbyterian/Weil Medical, Cornell..etc?

Second, if a family member of yours could be ridden of type 2 diabetes, wouldnt you want to know?

For those who think they know about gastric bypass surgery, this isnt gastric bypass. Rather it is "duodenal jejunal bypass."

And those that represent the "medical" community, you are either jealous, in complete disbelief, or just ignorant. Dont assume something before you thoroughly understand it.

If my father (who has type 2 diabetes) was eligible for the surgery, I would take a loan out just to pay for it. Unfortunately he has had diabetes for too long and has been insulin dependent over 10 years so he is not a candidate for the surgery. Learning of this was very upsetting to him and the rest of my family. So, if there is a possibility Dr. Rubino can save someone (who could have been my dad ten years ago) then we ought to give him more than just the nobel peace prize.

Posted by Anonymous on 16 March 2009

One of the things I told the internists when was trying to figure out what was wrong with me was "I don't think that my body is properly digesting the food I eat." How interesting to see that physical changes to the intestine and therefore the capacity to digest food impacts diabetic symptoms.
I went to 3 Internists, NOT ONE of WHOM bothered to test my blood sugar before I gave up and lived with it. Only 2 YEARS later, when my brother ended up in the hospital from complications associated with his undiagnosed diabetes was I able to go to an internist and say my brother has diabetes and I want to be tested. Surprise, Surprise I have type II diabetes. I'm not ready for surgery. I'm fighting this with diet and exercise and metformin. But it is very interesting to read. MORE Research is needed.

Posted by Anonymous on 4 June 2009

My type 2 started a few years after having stomach issues.(10 years ago) Faltulance and burping.
I was told that i was swallowing air but observers could not agree.I was sure that my food was being digested by something else.

4 doctors later I was seen as a hypocondriac as none of thier expensive potions had any effect.

Now they just prescribe anti depressants...

They do their best but this seem really a worth while area to investigate as whilst I am no doctor , Im sure it started in my gut as well.

This reminds me of the helico bactor (stomach ulcer)story of 20 years ago.

My current gp dismissed this out of hand with out even looking into it.
That is why they are called "practices" because they have not got it right yet. It is a pity they don't practice a bit more and listen the their patients, and when they seem impatient, they prescribe head drugs!

No! I don't want to join the lets be sick diabetes clubs.

Diet control is still (just ) working for me

Lindsay Mannix Perth WA

Posted by Anonymous on 16 August 2009

I would volunter to be a test subject in a minute. Anytime any where. I am only mildly overweight about 15 pounds but I have been living with this for over 12 years and I have been out of control for most of those years, I welcome a chance for a normal life and perhaps a longer life span. To see my wonderful twins go up

Posted by Anonymous on 13 October 2009

I am one of Dr. Rubino's patients and will have the duodenal/jejunal bypass in a few weeks. I've followed his research for 2+ years and when he was hired at New York Pres I tracked him down, and told him I wanted to be part of any clinical studies he does. I've had type 2 diabetes for 7 years and been taking insulin for the last 3. My sugar is out of control, I can't lose weight, but I'm not heavy enough to qualify for regular gastric bypass.

To those nay-sayers out there - keep in mind a few things:
-diabetes goes into remission within days of the surgery... check out the peice on 60 minutes (just google Rubino and 60 minutes and you'll find the clip).
- this is more than just managing the diabetes, it's REMISSION!!!
- the medical community, to this point, has failed diabetics (type 2).... if it hadn't, we wouldn't have an epidemic on our hands

In any event, I'll let you all know what happens after the surgery.

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