Surgery Putting Type 2 Diabetes Into Remission
Marilynn Marchione, AP
New research gives clear proof that weight-loss surgery can reverse and possibly cure diabetes, and doctors say the operation should be offered sooner to more people with the disease — not just as a last resort. The two studies, released on Monday, are the first to compare stomach-reducing operations to medicines alone for "diabesity" — Type 2 diabetes brought on by obesity. Millions of Americans have this and can't make enough insulin or use what they do make to process sugar from food. Both studies found that surgery helped far more patients achieve normal blood-sugar levels than medicines alone did.
The results were dramatic: Some people were able to stop taking insulin as soon as three days after their operations. Cholesterol and other heart risk factors also greatly improved. Doctors don't like to say "cure" because they can't promise a disease will never come back. However, in one study most surgery patients were able to stop all diabetes drugs and have their disease stay in remission for at least two years. None of those treated with medicines alone could do that.
"It is a major advance," said Dr. John Buse of the University of North Carolina at Chapel Hill, a leading diabetes expert who had no role in the studies. Buse said he often recommends surgery to patients who are obese and can't control their blood-sugar through medications, but many are leery of it. "This evidence will help convince them that this really is an important therapy to at least consider," he said. There were signs that the surgery itself — not just weight loss — helps reverse diabetes. Food makes the gut produce hormones to spur insulin, so trimming away part of it surgically may affect those hormones, doctors believe.
Weight-loss surgery "has proven to be a very appropriate and excellent treatment for diabetes," said one study co-leader, Dr. Francesco Rubino, chief of diabetes surgery at New York-Presbyterian Hospital/Weill Cornell Medical Center. "The most proper name for the surgery would be diabetes surgery." The studies were published online by the New England Journal of Medicine, and the larger one was presented Monday at an American College of Cardiology conference in Chicago.
More than one-third of American adults are obese, and more than eight percent have diabetes, a major cause of heart disease, strokes and kidney failure. Between five million and 10 million are like the people in these studies, with both problems. For a century, doctors have been treating diabetes with pills and insulin, and encouraging weight loss and exercise with limited success. Few very obese people can drop enough pounds without surgery, and many of the medicines used to treat diabetes can cause weight gain, making things worse.
Surgery offers hope for a long-term fix. It costs $15,000 to $25,000, and Medicare covers it for very obese people with diabetes. One previous study tested stomach banding, as this technique lowered blood sugar, but those patients had mild diabetes. The new studies tested permanent weight-loss surgery in people with longtime, severe diabetes.
At the Cleveland Clinic, Dr. Philip Schauer studied 150 people given one of two types of surgery plus standard medicines or a third group given medicines alone. Their A1c levels were over nine, on average, at the start. A healthy A1c is six or below. One year after treatment began, only 12 percent of those treated with medicines alone were at that healthy level, versus 42 percent and 37 percent of the two groups given surgery. Use of medicines for high cholesterol and other heart risks dropped among those in the surgery groups but rose in the group on medicines alone.
"Every single one of the bypass patients who got to six or less got there without the need for any diabetes medicines. Almost half of them were on insulin at the start. That's pretty amazing," said a study co-leader, Dr. Steven Nissen, the Cleveland Clinic's cardiovascular chief. An obesity surgery equipment company sponsored the study, some of the researchers were paid consultants, and the federal government contributed grant support.
The second study was led by Dr. Geltrude Mingrone at the Catholic University in Rome, with Rubino from New York. It involved 60 patients given one of two types of surgery or medicines alone. The researchers set as their A1c goal at under 6.5 — the level at which someone is considered to have diabetes. Two years later, 95 percent and 75 percent of the two surgery groups achieved and maintained the target blood-sugar levels without any diabetes drugs. None of those in the medicine-alone group did.
There were no deaths from surgery and only a few complications. Four patients in the Cleveland study needed second surgeries, and two in the Italian study needed hernia operations. Doctors note that uncontrolled diabetes has complications, too — many patients wind up on dialysis when their kidneys fail, and some need transplants.
The government recently lowered the criteria for use of gastric bands from a BMI of 35 down to 30 in diabetics or people with heart disease, opening the way for wider use of this and other procedures for obesity. Dr. Alvin Powers, director of the Vanderbilt University diabetes center, said the results are very encouraging for people like those in these studies — very obese, with diabetes that can't be controlled through less drastic means.
The studies "are likely to have a major effect on future diabetes treatment," two diabetes experts from Australia, Dr. Paul Zimmet and George Alberti, wrote in an editorial in the medical journal. Surgery should not be seen as a last resort and should be considered earlier in treating obese people with diabetes, they wrote.