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A Big Bone of Contention: Should Bariatric Surgery Become a Standard Type 2 Diabetes Therapy?


Oct 24, 2009

A recent and contentious meeting of diabetes experts at the European Association for the Study of Diabetes in Vienna, Austria, has continued the intense international debate over whether bariatric surgery should become a treatment for type 2 diabetes or continue to be reserved only for the extremely obese.

In bariatric surgery, the stomach is either reduced in size or completely bypassed so that food directly reaches the small intestine. In either case, the amount of food that can be eaten and the appetite for it are lowered significantly. Bariatric surgery not only leads to dramatic weight loss by severely restricting food intake, but it also lowers the high risk of cardiovascular disease that comes with obesity.

But a fortuitous side effect has put the procedure front and center in a wide-ranging debate over how the surgery should be perceived and used. Most obese people with type 2 diabetes who undergo bariatric surgery see dramatic improvements in their blood glucose levels and insulin sensitivity within days, often to the point of complete remission of the disease. A Swedish meta-analysis of 600 studies of the long-term effects of bariatric surgery showed that 86.6 percent of type 2 patients who underwent it experienced improvement in their condition and 78.1 percent experienced "complete resolution" of their diabetes-essentially a cure.

However, current guidelines restrict the procedure to patients with a body mass index of 35 or greater-the "morbidly obese." Many people with type 2, therefore, do not qualify for the surgery. It is this fact that is the center of the current controversy. The debate in Vienna, as reported in heartwire, focused on whether the surgery should become a staple therapy for treating type 2 diabetes.

Both sides acknowledged that while the surgery's effects on type 2 diabetes are compelling, there are no data on people with BMIs of less than 35 who have undergone the surgery. Until there are such data, it will be difficult to determine whose argument will carry the day. Consequently, the proponents of bariatric surgery for type 2 patients are in a chicken-and-egg situation: They can't prove their thesis until they have more surgeries on non-morbidly obese people under their belts, but they can't perform those surgeries because such people-for the foreseeable future-are denied access to it.

Advocates for the surgery on type 2 patients said that BMI should not be the primary factor in determining eligibility because there are other markers in type 2s that indicate a vulnerability to cardiovascular disease. In such patients, whose BMI may not qualify them for bariatric surgery, the fact that they have a known risk that can be mitigated by a known procedure should be grounds enough to let them undergo it. They also pointed out that some U.S. insurance companies and health plans are mulling over whether to accept the surgery as a treatment for metabolic disorders like diabetes and not just as an exclusive therapy for morbid obesity.

Opponents argued that allowing bariatric surgery to become more common might ultimately end in the realization that the medical community had taken a wrong path. One expert recalled the popularity in the 1930s and 1940s of the lobotomy, a surgery on the prefrontal lobes that was designed to treat or even cure severe psychoses or behavioral disorders. Not only did the surgeries irreparably harm patients, but the need for them disappeared with the introduction of drugs to control many of the conditions that lobotomies were intended to address. In that vein, one endocrinologist asked if there might not at some point be drug combinations that could produce the same results as bariatric surgery, but without its body-altering effects.

The next step toward resolving the debate is a long-term study of the effects of bariatric surgery on lower-weight type 2s. There is some talk that Britain may fund a 10-year study, but other than that, there is no major research underway on the topic.

* * *

Sources:

Experts debate bariatric surgery as a cure for diabetes

October 8, 2009 | Lisa Nainggolan


Categories: Bariatric Surgery, Blood Glucose, Diabetes, Diabetes, Food, Insulin, Type 2 Issues, Weight Loss



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Comments

Posted by Anonymous on 24 October 2009

The problem I faced when trying to have bariatric surgery was, my insurance company refused to pay for it, insisting that it was cosmetic and not medically necessary. My doctors had sent letters to them telling them it was medically necessary and still my insurance company refused to pay for "cosmetic" surgery. It seems to me the ones who need convincing are the insurance company powers that be. I have friends who have had bariatric surgery, and in every case, those who had DM2 were all cured of their disease.

Posted by Zola on 24 October 2009

I have always beleive that baratric surgery could possibly be the cure for Dabetics... yr ago I had mentioned this to him .just to see if it would work for me. Cause i believe that if it was done maybe just maybe I would be cured....many Drs' feel that othr countries experiment. really does't meet up to our countries standards but I feel. that if they did it would help our society. and the evr climbing bills of Diabetes... All I'm saying is Doc's lets keep an open mind....give it a try. American Doctors.....

Posted by ndocroth on 24 October 2009

How long are we overlooking that bariatric surgery bypasses those areas of the small intestines commonly affected by celiac disease?
Individuals with the HLA-DQ2 and HLA-DQ8 type (common in celiacs and diabetics) miss an enzyme needed to digest grain carbohydrates. There thus may be a non-surgical solution afterall: Advise diabetic patients with the typical abdominal obesity to completely avoid grain carbs.

Aren't most diabetics "hooked" on grain-based comfort foods? Gluten (same as casein in lactose) contains opioid exorphins in an amount significant enough to create carb addiction - so much for that comfort! The body cannot process it and is forced to store it in its ever-growing fat cells.

Already research has established the type 1 diabetes - celiac disease link. Type 2 diabetics too can benefit from a gluten-free lifestyle by eliminating the accumulative inflammation responses.

- author of "At Risk? Avoid Diabetes by Recognizing Early Risk - A Natural Medicine View" and the "Diabetes-Series Little Books."

Posted by pattyl on 24 October 2009

My H was diagnosed type 2 about 10 years ago. He was pretty normal weight wise, BMI 26 or 27. He also had neuropathy in his feet and retinopathy. He went to Spain and had the DS for diabetes 6 years ago and never needed another dose of meds. It was just gone. His retinopathy went away completely. There is a huge difference between treating diabetes and curing the disease. His vision returned to 20/20 without glasses. He does have permanent nerve damage in his feet and they will never be normal.

The DS for diabetes has been done for more than 15 years in Europe and it works. 98% of the time. Those are darn good odds! H's doc was Aniceto Baltasar in Alcoy, Spain.

My friend also had the surgery. He had been an insulin dependent type 2 for over 30 years. It took him about a month to resolve his diabetes completely but it did go away.

Everyone I know who had the surgery is happy and healthy years later. And they eat what they want. Including sugar and fat. Another great side effect is that it COMPLETELY gets rid of hyperlipidemia as well. Post op, you probably have the cholesterol of a 10 year old.

I've been talking about this for years and the diabetic community laughed at me because what I was saying flew in the face of what they were told by their docs and diabetic educators. I hope you will hear me now. At least enough to check this out for yourselves. The horrors of type 2 are not inevitable. You can choose to fix it.

Posted by pattyl on 24 October 2009

And by the way, there is a cohort of patients available who can be studied. People who have had the surgery in the last 15 or so years.

The cure has nothing to do with food restriction, weightloss, or exercise. It has nothing to do with the size of the stomach. It has everything to do with the actual intestinal bypass.

Did you ever stop to think Diabetes is a multi-billion dollar industry?

Posted by larry528 on 24 October 2009

I am 59, have been type 2 for 25 years. I was insulin resistant, taking 300 units 75/25 mix a DAY, I used a c-pap. I weighed 285 when I had short limb gastric bypass done. 7 months later I am down to 190 a weight I havent seen since my middle teens. I am still needing insulin, some days I can get by with 20 units, but most days its 30 units a day. I never had BP or cholesterol problems before surgery, but I had lipid problems that required medication to get down to under 200. My recent blood work I had cholesterol under 100, low BP, normal unmedicated lipids. I no longer use the c-pap, I no longer take lipid meds. I have eliminated most medstaking a lower dose of synthroid.

I wish I did this years ago. When I see my diabetes doc, I ask him if my results is making him reconsider the surgery. He never recommended it, it was done purely on my own since I was always losing and gaining with traditional diets.

Posted by Anonymous on 24 October 2009

Type 2 diabetes is CURABLE if it is treated by a duodenaljujunal bypass before the insulin-producing cells are exhausted and killed by years of being forced to overproduce insulin to compensate for insulin resistance. The insurance companies and pharmaceutical companies are the ones who are balking at allowing this life-saving treatment to be offered to patients who are left to suffer instead.

By the way, the fallacious strawman argument of referencing lobotomies is ridiculous -- the duodenal-jejunal bypass can be tailored in limb length to the individual, and can be revised or reversed if necessary, via laparoscopic surgery -- something that is not true of a lobotomy.

As a duodenal switch bariatric patient myself (which comprises both a duodenal-jejunal bypass and a vertical sleeve gastretomy to treat morbid obesity), and a patient advocate who helps people get recalcitrant insurance companies to pay for their bariatric surgeries (and as a lawyer and a PhD in biochemistry as well), I have seen hundreds if not THOUSANDS of patients whose type 2 diabetes has been CURED by this surgery. It is an OUTRAGE that a known surgical treatment -- CURE! -- for type 2 diabetes is being withheld from patients in the US.

Posted by larry528 on 24 October 2009

I am 59, have been type 2 for 25 years. I was insulin resistant, taking 300 units 75/25 mix a DAY, I used a c-pap. I weighed 285 when I had short limb gastric bypass done. 7 months later I am down to 190 a weight I havent seen since my middle teens. I am still needing insulin, some days I can get by with 20 units, but most days its 30 units a day. I never had BP or cholesterol problems before surgery, but I had lipid problems that required medication to get down to under 200. My recent blood work I had cholesterol under 100, low BP, normal unmedicated lipids. I no longer use the c-pap, I no longer take lipid meds. I have eliminated most medstaking a lower dose of synthroid.

I wish I did this years ago. When I see my diabetes doc, I ask him if my results is making him reconsider the surgery. He never recommended it, it was done purely on my own since I was always losing and gaining with traditional diets.

Posted by Anonymous on 24 October 2009

Type 2 diabetes is CURABLE if it is treated by a duodenaljujunal bypass before the insulin-producing cells are exhausted and killed by years of being forced to overproduce insulin to compensate for insulin resistance. The insurance companies and pharmaceutical companies are the ones who are balking at allowing this life-saving treatment to be offered to patients who are left to suffer instead.

By the way, the fallacious strawman argument of referencing lobotomies is ridiculous -- the duodenal-jejunal bypass can be tailored in limb length to the individual, and can be revised or reversed if necessary, via laparoscopic surgery -- something that is not true of a lobotomy.

As a duodenal switch bariatric patient myself (which comprises both a duodenal-jejunal bypass and a vertical sleeve gastretomy to treat morbid obesity), and a patient advocate who helps people get recalcitrant insurance companies to pay for their bariatric surgeries (and as a lawyer and a PhD in biochemistry as well), I have seen hundreds if not THOUSANDS of patients whose type 2 diabetes has been CURED by this surgery. It is an OUTRAGE that a known surgical treatment -- CURE! -- for type 2 diabetes is being withheld from patients in the US.

Posted by Anonymous on 24 October 2009

I had Roux-N-Y surgery to try to cure type 2 diabetes in 2003. I remained insulin dependant.In 2006 I developed dumping syndrome and now require a shot of Octreotide monthly - it's a $1800.00 shot - and I am still getting very sick after each meal. This surgery is not the magic cure for diabetes and the possible side effects are serious. Also, almost everyone I know has put the weight back on after a few years. Watch what you ask for - you may get it!

Posted by Anonymous on 25 October 2009

Yes it works. Yes people have very serious complications. Yes people die.

As a radiologist MD, I see serious complications associated with these procedures.

I am often amazed that patients and the medical community are willing to re design someone's digestive track, often at great risk, yet are not willing to subject patients to low carb diets. Is it the fear of fat?

Study after study shows that low carb for diabetes works. Yet there is some insane fear of this approach. Certainly any perceived risk of low carb is far less than the permanent alteration of a GI tract.

Surgery should be an absolute last resort.

DJ

Posted by Anonymous on 26 October 2009

The effect of bariatric surgery on Diabetes type II in Obese people is well-known and well studied. However for lower BMI diabetics it is important to confirm the type of diabetes. Asians with predominantly central obesity develope Diabetes Mellitus at a lesser BMI, so are benefitted by surgery even if operated at lower BMI for uncontrolled DM II.

Posted by pattyl on 26 October 2009

To Dr. DJ

I agree surgery shouldn't be the first avenue of treatment. But it is an option everyone should be told about. It should be the patient's choice.

Low carb does work. I cringe when I read the sugar count in products designed for diabetics. The only carbs my H ate were green vegetables. His HA1C was normal but his diabetic opathies were still getting worse. He saw his future as blind in a wheelchair. Yes he knew every risk of surgery and he decided it was worth the chance. It's always risk vs benefit.


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