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CDE,MBA,RD
Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12
Section:  General Diabetes

Two new studies released today (3-26-12) find that weight-loss surgery is significantly more effective than standard treatments for controlling blood sugar in overweight and obese people with Type 2 diabetes.

 

Although research has previously hinted that bariatric surgery, which shrinks the stomach and reroutes food to the intestines, can reverse diabetes — sometimes even before patients leave the hospital — the two new studies published Monday in the New England Journal of Medicine are the first randomized trials to pit surgery against standard treatments head-to-head.


Compared with patients getting blood-sugar-controlling medication and counseling in diet and exercise, those who received bariatric surgery were far more likely to be free of diabetes or to have reduced their dependence on diabetes medications for at least two years, compared with those not getting the surgery.

 

In one study, led by Dr. Francesco Rubino of Weill Medical College of Cornell University and author of one of the studies and his colleagues at the Catholic University in Rome, 75% of the patients who had bariatric surgery no longer had diabetes after two years, compared with zero patients who relied on drug treatments alone.


In the second trial, led by researchers at the Cleveland Clinic, 37% to 42% of patients having the surgery and using diabetes medications were able to keep their blood glucose levels below the threshold doctors use to diagnose diabetes, compared with  12% of those who depended only on the medications, after a year.


“The result is simply stunning,” Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic and an author of the paper, told USA Today.


Researchers are still investigating how the reversal of T2 diabetes occurs so quickly....before wt loss even is realized....but postulate that it is due to hormonal changes, especially in the gut.  


My thought is that this may be the hormone incretin, which we know is deficient in T2 PWDs.

Read more: http://healthland.time.com/2012/03/26/weight-loss-surgery-works-better-than-drugs-to-control-diabetes/#ixzz1qGYlS3Sx


Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

 

 

MEMBER COMMENTS
Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Mary Ann -

Thanks for bringing our colleagues attention to these two studies in this week's New England Journal of Medicine, March 26, 2012. I'm chuckling b/c today's Washington Post (my daily read) covered it in the front section but I had a tough time grabbing that section from my husband this morning. (Trust me, he was not reading this story.) Finally got it and read it!

Always glad to see diabetes management in the public headlines. And today is a big diabetes day b/c it's Diabetes Alert Day.

I would ike to add to your content that there is an editorial in this same NEJM issue which draws discussion from both studies. The title is Surgery or Medical Therapy for Obese Patients with Type 2 Diabetes. The editorial is by two international leaders/well known experts in the diabetes world - Paul Zimmet, M.D., Ph.D., and K. George M.M. Alberti, D.Phil.

I've read the editorial (have not quite gone thru the studies yet).It is well written, short and worth the read. A few conclusion and an important reference:

- They note the huge challenge we are realizing of helping people with type 2 manage this progressive disease despite more and better medications.

- They comment about who would have thought back when insulin was discovered that we'd ever be talking about using surgery as a "cure" for type 2.

- Mingrone, et al. (Italian study with Rubino, well know surgery proponent in U.S.). People had either Roux-en-Y or biliopancreatic diversion vs. medical management. People were tracked for two years. Remission was 75% for Roux-en-Y and 95% for biliopancreatic diversion compared to no remission for medical management.

- Schauer et al. from Cleveland Clinic (Schauer is another well known bariatric surgeon who's been a proponent of this surgery in type 2 diabetes). They compared intensive medical therapy with gastric bypass or sleeve gastrectomy. At the one year point (seems like they are tracking these people in the future), A1c of 6% or less was attained by 12% of sujects receivng medical management  vs. 42% for bypass surgery and 37% for sleeve gastrectomy.

The editorial authors make the point that we can't yet call surgery the panacea for treating type 2. They note studies have been short term and conducted with a small sample size.They raise the issue that surgery, particularly in this at risk population, has risks during surgery and afterwards. They make note of the psychological challenges to these individuals.

Several times they point readers to the consensus statement published several years ago by ADA. I've read it a few times and it's excellent. It actually speaks to how we define "cure" or "remission" for both type 1 and type 2. I'd encourage people to give it a read: Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes? Diabetes Care 2009;32:2133-5. It's easily accessible on ADA's professsional side of their website.

Interestingly I'm having the joy of watching two people in my life who have/had type 2 diabetes and bypass surgery in the last year. They are both making tremendous progress both in their weight loss and diabetes control.

Thanks,
Hope Warshaw, MMSc, RD, CDE, BC-ADM
Nutrition Section editor, PRESENTdiabetes.com

 

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Actually, what I understood from reading the Cleveland Clinic Study is that  overweight patients with diabetes who underwent bariatric surgery "achieved significant improvement or remission of their disorder". These patients are not and will not be diabetes -free. It is very important to keep in mind that 27 or so genes are involved in the development of Type 2 Diabetes in combination with various environmental triggers.

I currently have 3 patients who had bariatric surgery 3-6 years ago. They are not able to control their blood sugars and struggling to keep their A1Cs between 7 and 7.5%.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

I have to say that I initially cringed when I read the headlines about this study. Here's why:

- several of my clients have told me that they know gastric surgery is a tool, and that the surgery by itself isn't the answer. They have to learn how to eat post-surgery and most importantly learn how to deal with emotions and stress without using food. Surgery doesn't change the need for changes in habits.

- I routinely see people who had gastric surgery more than 5 years ago, who have zero follow-up in regards to vitamin/mineral status. I'm seeing them because they are regaining weight and feeling generally awful.

- What about folks with T2 who don't meet the weight criteria for surgery? Should we lower those criteria?

- Several of my clients told me their PCP encouraged them to have surgery, but they're hesitant because they're afraid that they'll switch their 'addiction' (their words) to food to another addiction, such as alcohol or smoking.

- Insurance companies are willing to pay for bypass surgery, yet they don't reimburse for education for folks diagnosed with pre-diabetes or help make exercise programs more affordable.

I do believe that gastric bypass surgery is an option, and often a really good option, for many people. But I hestiate to label it as a cure, which seems to indicate that it's something that just about every overweight person with T2 should plan on having as part of their treatment program.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Hey, Lynn, you struck a cord about bariatric surgery pts trading one addiction for another.

In 2005 Barbara Thompson, the then president of Weight Loss Surgery Center, a Web site for weight-loss-surgery patients, started getting e-mails asking if she'd heard of anyone "having a problem with alcohol after surgery—when they'd never had a problem before".


From the literature I read about this issue, here is a brief summary:


This "addiction transfer," is a phenomenon in which patients who have undergone weight-loss surgery—and no longer abuse food—begin abusing, among other things, drugs, alcohol, money, sex and even shopping.


Most of these people are trapped in food addiction due to their underlying emotional and/or mental triggers. Without learning coping habits and unable to turn to food after surgery, many will pursue other harmful and self-destructive behaviors with what's known as 'addiction transfer'.  


Experts claimed in 2007 that no more than 5 percent of such patients experience addiction transfer....but this is still many, many patients.   One study patient, post-surgery, turned to shopping—and racked up $15,000 in debt.


I read in another article that what's really scary is that patients who have had a gastric bypass operation take longer to process alcohol, potentially leading some of them to overindulge when drinking. 


In this same article it was reported that patients (per a study) who display binge eating behavior prior to their operation have the highest likelihood of post-operative alcoholism.


Can put a bandage on a wound, but have to cure the underlying infectious disease, right?


On the other hand, some people need the bandage to survive....literally.


 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

 

Eat Well, Laugh Often, Love Much



Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

I am in agreement with you all...there is little follow up with the patients I've "found" and they all have difficulty with managing their diabetes, as most of them have gone back to the way they were eating prior to the program.  It's not to say that for those that do have follow up they aren't successful.  Just one more "tool" in the tool box. 

Also have seen vitamin deficiency issues as well.

 

 

 

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

I consider weight loss surgery "trash medicine."  It is poorly done, often riddled with deliberate and unethical manipulations and harmful to society.  It is bad enough that I have T2 diabetes, but it really pisses me off that this harmful stuff is being pushed as a cure when it fact is far worse than doing nothing.

Jenny Ruhl has some biting words about this study in her blog.   From her analysis, it should be clear that the results are hardly stellar and far from a cure or even remission.  In fact, in follow up, many of these patients who suffered surgery will still be diabetic but will have unstable blood sugars due to the inability to digest normally.  They cannot eat normal amounts of food and the proper mechanisms for releasing food from the stomach into the intestine will never work correctly (this is a central element of gastroparesis).  And one thing which Jenny doesn't note is that these sorts of studies which have an inherent conflict of interest (Cleveland makes huge amounts of money doing these surgeries) often cannot be trusted to remove "selecton bias" from their studies.  Even without the media spin on the actual results, you still can't trust them.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Hey, Brian...I missed hearing from you in the last week or so......on vacation?


Re: your comments above, I still am of the firm belief that there is a small population of individuals that can and will benefit from bariatric surgery, whether they have diabetes or not.  


I hear what you're saying about the complications that can ensue from the surgery (e.g., gastroparesis) and what others have said in this blog about addiction transfer and the like.


However, when survival literally depends on a huge amount of fat loss, and the person simply cannot do it on his/her own (for any of the myriad of reasons....it is what it is, as they say), then what other choice do these people have?


Really......what other choice to survive??


Anyone else want to chime in here?


Mary Ann Hodorowicz, RD, CDE, MBA, CEC

Re: Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12
Quote:

Hey, Brian...I missed hearing from you in the last week or so......on vacation?


Re: your comments above, I still am of the firm belief that there is a small population of individuals that can and will benefit from bariatric surgery, whether they have diabetes or not. 

It is really good to hear that I was missed, I'm not always sure how this community feels about me posting here as an "opinionated" patient.  I have not been on vacation, but I have had to travel 2.5 weeks out of the last month.

And while there may well be a population for which bariatric surgery is really appropriate and helpful, this is not the way that medicine works.  We have already seen pressure to deem bariatric surgery appropriate for people with lower BMI's.  Should the "establishment" accept bariatric surgery as a treatment for diabetes, it will be pushed as appropriate for a broader range of patients, most which I would consider inappropriate.  I would agree that a patient who has a BMI of 40 or more might be helped by such treatment, but what I can't figure out is why you can't at least try a low carb diet first.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

I would agree that a patient who has a BMI of 40 or more might be helped by such treatment, but what I can't figure out is why you can't at least try a low carb diet first.


Brian, asking an extremely overwt person with a BMI > 40 who is looking at death unless significant wt loss is acheived to "Just try a low carb diet first" is extremely unrealistic, in my opinion.


Most HCPs are keenly aware of the immense psychosocial issues (and many times psychiatric issues) that plague these individuals.....it's not WHAT they're eating....it's what eating THEM.  One of the biggest criticisms of this surgery is that the bariatric healthcare team doesn't get to core of exactly this issue, hence often resulting in pts regaining the wt.


But first things first: his life must be saved first.  Yes, extreme measures are sometime required for extreme life or death cases.  And this is were bariatric surgery steps in.


Mary Ann Hodorowicz, RD, CDE, MBA, CEC

 


 

 

Re: Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12
Quote:

I would agree that a patient who has a BMI of 40 or more might be helped by such treatment, but what I can't figure out is why you can't at least try a low carb diet first.


Brian, asking an extremely overwt person with a BMI > 40 who is looking at death unless significant wt loss is acheived to "Just try a low carb diet first" is extremely unrealistic, in my opinion.


Most HCPs are keenly aware of the immense psychosocial issues (and many times psychiatric issues) that plague these individuals.....it's not WHAT they're eating....it's what eating THEM.  One of the biggest criticisms of this surgery is that the bariatric healthcare team doesn't get to core of exactly this issue, hence often resulting in pts regaining the wt.


But first things first: his life must be saved first.  Yes, extreme measures are sometime required for extreme life or death cases.  And this is were bariatric surgery steps in.


Mary Ann Hodorowicz, RD, CDE, MBA, CEC

 


 

 

I agree.  I was thinking of a colleague this morning.  She is an RN and approached me for help with weight loss.  She said she didn't understand why she couldn't lose wt.  When I asked her about her current eating habits she said, 'well, lastnight I sat down and ate an entire cherry pie'.  I said, 'ok, for starters, don't do that'.  

I wish it was that simple.  Now in this scenario we were both being a little flippant and not really trying to get to the heart of the matter.  She had just approached me in the hallway.  But really, when a person with a BMI >35 is in my office for wt loss I sometimes feel helpless.  

If the person truly does not know what to eat or avoid then yes, I can help them.  But most of them have tried and re-tried to lose weight to no avail.  They know what they should be eating and what they should be avoiding.  They can usually tell me what they need to do!  They know that eating a whole pie is not going to help matters any but for some reason they cannot stop.  I usually suggest counseling, therapy, or Overeater's Anonymous.  

I have seen the research and it is compelling what weight loss surgery can do for some people.  Prior to looking into the research I thought they were just putting the diabetes 'in remission' due to the weight loss but the research makes it clear that there are other mechanisms at play in the gut and possibly in the fat itself that are driving the obesity and that halting those mechanisms with the gut resections, etc can make a difference.  



Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

I have a dear friend who falls in this category.  A low carb diet is the only way he has any hope of losing weight.  It has nothing to do with lack of control, it is about a seriously messed up metabolism and hyperinsulimia.   A low carb diet is certainly preferable to surgery.  Whether it works or not is another question.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Several of my doctors have suggested I have the surgery, so I looked into it. Please follow the links as I did…

1)      Cleveland Clinic has a website campaign promoting this surgery and it sounds like a dream come true.  

2)      Malnutrition is a common problem for the obese both before and after the surgery. It’s VERY expensive not only for the surgery and follow-up, but the supplements and protein products you need just to get the minimum requirements requires a substantial lifetime income.

3)      I would be trading one health problem for others far worse like bone loss , and hypoglycemic episodes . Notice who is presenting this powerpoint at a conference. (an authority in the field)

4)      So I looked at the diet thinking maybe that might contribute to  the success everyone claims is from the surgery

5)      So perhaps I could follow these guidelines, but the number of foods I will no longer be able to tolerate are packed with nutrients, some of which we are just beginning to discover that aren’t in supplements

6)      People who have this done may lose the weight, but face decades of malnutrition and often no support in handling the emotional and physical toll.

7)      So instead maybe lap-band might be possible, till I saw this. My sister had the procedure and suffers from advanced bone loss of the spine and protein related deficiencies since the stomach is a major contributor in protein digestion. She is also regaining her weight and her surgeon has dropped her from the “study” now it has been 5 years and referred her to a bone specialist. He no longer has to include her deteriorating health in followups, how unethical!

8)      I choose LIFE with diabetes and feel that there is never a good reason to mutilate yourself for normal blood sugars, ESPECIALLY since there are other ways to do it. I had normalized blood sugars within a week of following Dr. Bernstein’s Diabetes Solution advice and if you advise diabetics, I encourage you to buy a copy of his book. I don’t understand why it isn’t encouraged more as soon as a PWD is diagnosed.

9)      I was 290 lbs. on a 5’2” frame (>50%BMI) when I began the South Beach Diet and have lost 45 pounds and am still losing with an even closer to normal blood sugars by following the Bernstein guidelines. Protein and fats and nutrients found in low-glycemic carbohydrates are essential for good health. If I had at least been given the option, I might not have gained so much on the ADA diet, which being compulsive I followed very closely.

10)    All this garbage about eating 45-65% “healthy” carbohydrates is dangerous advice for type 2 diabetics trying to lose weight. Even studies the USDA Guidelines group looked at proved that the (satiety) incretin GLP1 level was stronger in lower carbohydrate diets studies here,  here, and here.  No wonder I was hungry all the time following a “healthy” diet!

 

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Bonnie: I'm interested in the foods you might purchase.  Do you buy modified foods, like the items sold by Dr. Barry Sears?  http://www.zonediet.com/medwell

I'm not marketing for him, but I've met with him and these seem interesting to me, but costly.  Just wondering.....

 

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Thanks for asking, Joan. Most foods I buy come from the local Kroger, Meijer, Trader Joe, or Whole Foods. Kroger has inexpensive organic veggies, a great low-carb yogurt CarbMaster, Hood's low-carb milk and chocolate milk Calorie Countdown, sugarfree pickles, and 1 carb Hunts Ketchup, and good selection of frozen fish. I only use Splenda with fiber or lactose, and Stevia with fiber for sweeteners. For fiber, I like chia seeds, ground flax seed, and Wasa Fiber crispbread and spinach/other greens. I enjoy cream, butter from Ireland, Greek yogurt, grass-fed beef, Greek and Italian Olive Oil, organic veggies, tuna, miso, and tofu from Trader Joe or Whole Foods. Meijer has a great selection of nitrate-free meat, poultry, fish, eggs, veggies, cheeses, and International foods like real fermented German sauerkraut, and Mediterranian condiments. I use almond flour or crushed crispbread for breading, soya powder or almond flour for baked goods, and real cream, tasteless fiber supplement, gelatin, or egg yolk to thicken sauces.

I have a few favorites I order on the Internet:

Splenda tablets that have a filler that doesn't increase my BG like maltodextrin does

DaVinci sugarfree syrups to add to recipes

ChocoPerfection chocolate bars - I eat one dark chocolate square each night mmmm..

I haven't found a protein powder I like yet, so drink the Hood's Calorie Countdown chocolate milk after a workout. I drink freshly brewed decaf green tea, decaf Constant Comment tea, Club Soda or soymilk with flavorings(Vanilla Chai Soymilk-yum), and diet gingerale when not water.

May seem expensive, but we avoid the chip, bread, cookie and cereal aisles so it evens out.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

MaryAnn  you are right, I believe, that it is the gut hormones (and I don't think we know about all of them) specifically the dipeptidyl peptidase  and GLP1.   These are both incretins.  The word incretin, I believe was made up as we understood the gut contribution better.  It stood for "intestinal secretion of insulin".

Re: Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12
Quote:

MaryAnn  you are right, I believe, that it is the gut hormones (and I don't think we know about all of them) specifically the dipeptidyl peptidase  and GLP1.   These are both incretins.  The word incretin, I believe was made up as we understood the gut contribution better.  It stood for "intestinal secretion of insulin".



Hi Christine,

 

I had no idea about how the word "incretin" came to be!  Wow!  Thanks for sharing!  For those who have heard me speak, I am the "queen of acronyms"  (create and use them all the time) so this is right up my alley, so to speak!

 

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lecture

Eat Well, Laugh Often, Love Much

 

Re: Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12
Quote:

MaryAnn  you are right, I believe, that it is the gut hormones (and I don't think we know about all of them) specifically the dipeptidyl peptidase  and GLP1.   These are both incretins.  The word incretin, I believe was made up as we understood the gut contribution better.  It stood for "intestinal secretion of insulin".


I'm not sure about the word source.  What I did find says "Numerous experiments were performed and published between 1906 and 1935 testing the effect of injected or ingested gut extracts on blood glucose levels of normal and diabetic animals and humans, but with contradictory results. In 1932, La Barre introduced the name "incrétine" (incretin) for this proposed substance. "

There are two main incretins that have been found "Glucose dependent Insulinotropic Polypeptide" (GIP) and GLP-1.  They both are released into the bloodstream by the gut and increase insulin secretion.  There is an anti-incretin which inhibits the activity of GLP-1 called Dipeptidyl Peptidase-IV (DPP4).  Byetta, Victoza and Bydureon are GLP-1 analogs.  Januvia, Onglyza, and Tradjenta are DPP-4 inhibitors.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

I would much prefer that the medical community talk about gastric bypass surgery as one option, not a cure. It certainly isn't appropriate for everyone, there are many potential side effects and impacts on food choices and nutrient absorption as Bonnie mentions, and some people regain weight after the surgery, or trade one addiction for another.

We all know people who have lost weight and kept it off without surgery - look at the information in the National Weight Control registry. The more the media and the health community talk about gastric bypass surgery as a cure for diabetes, the more disservice we do to diabetes educators who promote healthy lifestyle changes, and those folks with diabetes who make those healthy choices on a daily basis and manage diabetes without surgery.

Re: Weight Loss Surgery Works Better Than Drugs To Control T2 Diabetes: 2 Studies Released 3-26-12

Lynn, your comments are right on the money!  How well said!  ....it's an option, not a cure.....it's not for everyone.....it doesn't work for everyone....the media should be careful how they word things (where have we heard this before?!).


Kudos to you!


Mary Ann Hodorowicz