Surgery For Diabetes?

One of the times I interviewed Dr. Mike Eades for Fat Head, he told me (after we were done shooting) that the usual treatment pattern for type 2 diabetes and other diet-related ailments goes something like this:

• Doctor puts patient on a low-fat diet
• Patient’s condition doesn’t get any better or gets even worse
• Doctor declares that diet won’t fix the problem and prescribes a drug

I’m afraid we’ll soon be seeing more and more of an alternate version of that treatment pattern:

• Doctor puts patient on a low-fat diet
• Patient’s condition doesn’t get any better or gets even worse
• Doctor declares that diet won’t fix the problem and recommends surgery

There were some dramatic headlines this week about a new study showing that weight-loss surgery works even better than diet or drugs (wow!) for reversing type 2 diabetes. Here are some quotes from a news story in the New York Times:

Two studies have found that weight-loss operations worked much better than the standard therapies for Type 2 diabetes in obese and overweight people whose blood sugar was out of control. Those who had surgery, which stapled the stomach and rerouted the small intestine, were much more likely to have a complete remission of diabetes, or to need less medicine, than people who were given the typical regimen of drugs, diet and exercise.

Hmm, I wonder what the typical regimen of drugs, diet and exercise would be? We’ll come back to that.

The new studies, published on Monday by The New England Journal of Medicine, are the first to rigorously compare medical treatment with these particular stomach and intestinal operations as ways to control diabetes. Doctors had been noticing for years that weight-loss operations, also called bariatric surgery, could sometimes get rid of Type 2 diabetes. But they had no hard data.

Experts say better treatments are desperately needed for the disease.

“Type 2 diabetes is one of the fastest growing epidemics in human history,” according to an editorial published with the two studies.

Yes indeed, rates of type 2 diabetes have been skyrocketing in the past few decades. Now … what’s changed in the population since, say, 1980? Have we been suffering from a shortage of bariatric surgery, whereas our grandparents all had their stomachs stapled as part of their high-school graduation ceremonies? I don’t think so.

One of the studies, conducted at the Catholic University in Rome, compared two types of surgery with usual medical treatment. After two years, the surgical groups had complete remission rates of 75 percent and 95 percent; there were no remissions in patients who received medical treatment.

The second study, at the Cleveland Clinic, compared two types of surgery with an intensive medical regimen. The remission rates one year after surgery were lower than in the Italian study — 42 percent and 37 percent — at least in part because the American study used a stricter definition of remission.

Sounds as if those Italians need to tighten up their definitions a bit. Otherwise we’ll have diabetics moving to Italy so they can become non-diabetics. The Italian Tourism Board may even start a new campaign.

Come to Italy! The scenery is a-lovely, the people are a-nice, and your fasting glucose will-a drop by 30 points!

I looked up the study conducted in the U.S. to see what “typical” regimen produced such lousy results compared to hacking up the digestive system. Can’t say I was surprised:

All patients received intensive medical therapy, as defined by American Diabetes Association (ADA) guidelines, including lifestyle counseling, weight management, frequent home glucose monitoring, and the use of newer drug therapies (e.g., incretin analogues) approved by the Food and Drug Administration.

Fabulous. The non-surgical patients were told to follow the ADA guidelines … you know, the guidelines that explain how carbohydrates drive up your blood sugar and therefore you should base your diet on them. Talk about rigging the game in your favor. That’s like spiking one team’s Gatorade with vodka before the Super Bowl.

Tom Brady is having a rough day out there. He’s been sacked six times, he’s been knocked down three times, and he’s fallen down 22 times for no apparent reason. I guess the Giants are just a better team, folks.

Every 3 months for the first 12 months, patients returned for study visits with a diabetes specialist at the Cleveland Clinic. Patients were counseled by a diabetes educator and evaluated for bariatric surgery by a psychologist and encouraged to participate in the Weight Watchers program.

Double fabulous. The patients were counseled by a diabetes educator. Here’s all you need to know about that: Hope Warshaw is a diabetes educator.

Then they were encouraged to follow the Weight Watchers diet – another low-fat diet. The researchers not only spiked the opposing team’s Gatorade with vodka, they added a few sleeping pills as well.

Folks, Brady just went down again despite not being touched, and I don’t think he’s getting up. This Giants defense is on fire today!

So we had one group of patients who were encouraged to follow a low-fat, high-carb diet and another group of patients who underwent surgery and – surprise! – the surgery group had higher rates of remission. Boy, mangling the digestive system Mother Nature gave us must perform some biological miracles.

It’s been nearly three years since I wrote about gastric bypass and lap-band surgery, so here’s a review of what patients are told to eat afterwards:

The second phase of the Lap-Band diet consists of 5 to 6 weeks of a modified full liquid diet; the key component of this phase is consuming two ounces of a protein shake every hour for ten to twelve hours a day with two ounces of other liquids such as soup, baby food, or sugar-free gelatin three times a day.

During the second six weeks following Lap-Band surgery patients may eat food that is shredded in a food processor prior to eating. The basic foods on the Lap-Band diet include meats or other forms of protein, vegetables, and salads.

After Lap-Band surgery the stomach will never hold more than 4 to 6 ounces per meal, so making every bite count is essential for healthy and nutritionally rounded weight loss success. Protein is especially important following Lap-Band surgery. The Lap-Band diet does not include most bread, potatoes and other starchy vegetables.

Surgeons reduce your stomach to an itty-bitty pouch, so you’re encouraged to base your itty-bitty meals on protein foods and vegetables while skipping the bread, potatoes and other starchy vegetables. In other words, it’s a low-carb diet … the itty-bitty version. Even if you ignored the advice and wanted to eat a big bowl of Kellogg’s Krave, you couldn’t. The itty-bitty pouch wouldn’t hold more than few ounces.

So we’re supposed to be impressed that people who undergo surgery and are limited afterwards to a few ounces of protein and vegetables end up reversing diabetes? Based on this rigged result, we’re perhaps going to start treating more diabetics with surgery – without first comparing surgery to a simple low-carb diet? What kind of doctors would promote that idea? Perhaps we should look at the disclosures in this (ahem) study:

Dr. Schauer reports receiving payment for board membership from Ethicon Endo-Surgery, Surgiquest, Barosense, RemedyMD, and Stryker, consulting fees from Ethicon Endo-Surgery, Stryker, Gore, and Carefusion, payment for expert testimony from Physicians Review of Surgery, and lecture fees from Ethicon Endo-Surgery, Allergan, Cinemed, and Quadrant Healthcare, holding a patent for a medical device to enhance weight loss in codevelopment with the Cleveland Clinic, royalties from Springer, having an equity interest in Intuitive Surgical, Barosense, Surgiquest, and RemedyMD, and receiving institutional grant support (to the Cleveland Clinic) from Ethicon Endo-Surgery and Bard Davol; Dr. Kashyap, receiving consulting fees from Ethicon; Dr. Brethauer, receiving consulting fees, lecture fees, and payment for board membership from Ethicon Endo-Surgery and lecture fees from Covidien; Dr. Kirwan, receiving grant support from Nestle and ScottCare.

Ah, I see. The study was conducted by a bunch of doctors who are paid by firms in the weight-loss surgery industry.

No other potential conflict of interest relevant to this article was reported.

Oh, that’s okay. I think the conflicts already reported were quite enough.