Bariatric Surgery and Type 2
In November 2010, Health Central sent me to Cleveland, where the Cleveland Clinic was having a conference on medical innovations for obesity. Several physicians spoke about about the benefits of bariatric surgery, especially the Roux-en-Y surgery, which seems to improve symptoms of type 2 diabetes as well as causing weight loss.
After the conference, I wrote about their experiences with surgery and weight loss, some of their opinions about obesity and type 2 diabetes as a disease, and some of the new approaches to weight loss. Some patients who had lost weight with the surgery also spoke.
This week, the popular press is excitedly reporting that bariatric surgery can cure type 2 diabetes. They're using words like "dramatic" and "groundbreaking" to describe the results.
First of all, this is not news. We've known for at least 5 years, maybe more, that when people get some types of bariatric surgery, their type 2 diabetes improves even before they've lost much weight. In some cases, they get off all drugs.
The same is true for people with metabolic syndrome, as reported in January at the annual meeting of the Southern Medical Association. This study was a meta-analysis that included 1,157 surgeons at 884 hospitals. Different surgeons used different techniques, but overall the surgical patients with metabolic syndrome showed improvements in "comorbidities" of their obesity, but slightly higher rates of adverse effects at 90 days than obese patients without metabolic syndrome.
What is new about the two studies reported this week in the New England Journal of Medicine is that they were randomized controlled studies that included a group of randomly chosen patients who got "conventional medical treatment" or "intense medical treatment" instead of surgery, so physicians can now have comparative statistics to show to their patients. Before this, there had been only one randomized controlled study of surgery and medical care.
The study with conventional medical treatment was done in Italy. The goal was an A1c under 7 after 2 years. The lifestyle changes included a low-fat diet and increased exercise.
The study with intensive medical treatment was done at the Cleveland Clinic, and the end points were measured after 1 year. Bill Quick has done a good summary of that study. The NEJM article didn't say what kind of a diet these patients were put on, but they say the medical therapy was "as defined by the American Diabetes Association," so one can assume they were given the standard ADA low-fat diet, like the subjects in Rome.
In both studies, the patients who had the surgery had lower BMIs, lower A1c's, and lower comorbidities like blood pressure and lipid levels, in most cases without medication. This is what the popular press is gushing about.
But what everyone is ignoring is the fact that in both studies, those randomized to the drug treatments without surgery also saw improvements. In the Cleveland study, the A1c in the control group went from 8.9 to 7.5 at one year. Still too high, and not as good as in those with the surgery (who ended up at 6.4 and 6.6 in the two surgery groups), but it suggests that further nonsurgical approaches might reduce it even further.
In the Italian study, the A1c of the control group went down 8%, and the A1c of the surgical groups decreased 43% and 25%. Again, the surgical group did a lot better, but the control group also improved. The bileopancreatic diversion surgery had the better results but also more serious nutritional deficiencies.
An accompanying editorial in the NEJM was more cautious than the popular press: "Is surgery, then, the universal panacea for obese patients with type 2 diabetes? We would answer, not yet."
At the meeting in Cleveland, one physician said that only about 1% of patients who qualified for the surgery went through with it, and he didn't understand why.
I did. It's major surgery, with a risk of complications, and even death. It's not easily reversible, if at all. For the rest of your life you have to deal with having a tiny stomach and poor absorption of some vitamins, so you have to be vigilant about taking supplements and tracking your nutritional status. The surgery can result in "dumping syndrome," in which your stomach empties too quickly, causing cramps and nausea.
True, without the surgery, a person has to deal with high blood glucose (BG) levels and tracking whatever they eat. High BG levels can cause complications and contribute to heart disease. And being overweight is a social handicap. So you're trading one batch of problems for another.
Obviously, the best solution would be to lose weight without surgery. But some patients have been trying to lose weight for their entire adult life, without success. Nevertheless, the patients in both of these trials did so, albeit not a lot. Could better support from medical advisors help them lose more without surgery?
Note that in both cases, the patients were on low-fat diets. What would happen if they were prescribed different diets until they found one that worked for them? Might a low-carb diet reduce the A1c as much as surgery?
Surgery can be useful, but I certainly wouldn't rush into it without considering all the other options. For someone with a lot of self-discipline who has tried other approaches without success, it might be worth the risks (people do die from this surgery, as they can from all major surgery).
The incretin drugs reduce hunger, so if uncontrollable hunger is the problem, they'd be a good bet before surgery. Low-carb diets reduce blood glucose levels, so if the overweight isn't as much of a problem as high A1c's, they'd be worth trying before surgery.
If all else fails, then surgery might be the answer for you.