There has been little but doom
and gloom on the diabetes front for years. But right
under our noses, people have been achieving "complete
disease remission" — not through drugs or lifestyle
changes, but through bariatric surgery, according to
a study in the January 23 issue of the Journal of
the American Medical Association.
Astonishing results have been achieved
in several high-quality studies, including the major
Longitudinal Assessment of Bariatric Surgery funded
by the National Institutes of Health. The latest study,
from Australia, assigned recently diagnosed type II
diabetes patients with body mass index in the 30-40
range to receive either gold-standard medical and lifestyle
therapy, or that plus laparoscopic adjustable gastric
banding (LAGB).
Fifty-five patients were followed
for two years. Of the thirty who received surgical intervention,
22 (73%) achieved 'remission.' Of the 25 on medical
therapy, only four (13%) achieved remission, with near
normal blood glucose levels - and these four had been
the patients with the mildest disease.
Mean average weight loss in the
surgical group was a whopping 20.7%, compared to just
1.7% in the medical therapy group. There were no surgical
complications and adverse events were roughly even in
both groups.
GUIDELINE
ADJUSTMENT
Results like that should make a splash, but in fact
this is the fourth major study in two years to show
that bariatric surgery can beat diabetes — though
the world's major diabetes associations have yet to
adjust their guidelines to accommodate this evidence.
In an editorial accompanying the
latest research, Drs David Cummings and David Flum bemoan
the inertia of the American Diabetes Association and
other national societies. "Although National Institutes
of Health consensus guidelines from 1991 indicate that
patients with diabetes and BMI greater than 35 can be
considered for bariatric surgery," they write, "more
than 90% of such individuals do not undergo these procedures,
and most are probably not referred for surgical evaluation
or even informed of surgical versus nonsurgical options.
Commonly used decision trees for diabetes treatment
currently do not mention surgery at all, even for severely
obese patients."
The Canadian Diabetes Association's
clinical practice guidelines do recommend bariatric
surgery as an option for patients with BMI over 35 who
don't respond to medical and lifestyle therapy. But,
ask Drs Frum and Cummings, why wait till then?
In fact, they argue, a bariatric
procedure in North America, the Roux-en-Y gastric bypass
(RYGB), offers even better prospects of diabetes remission
than does laparoscopic adjustable gastric banding. The
diabetes remission in the Australian study appeared
purely attributable to weight loss, they suggest, but
RYGB surgery can achieve the same weight loss while
triggering known anti-diabetic metabolic mechanisms.
About 84% of patients are achieving diabetes remission
with this technique, according to studies, say Drs Frum
and Cummings.
But overall, bariatric surgery
is proving itself safe and has been shown to bring a
mortality benefit. More research is certainly needed,
especially in more advanced diabetes, but this looks
like a treatment whose time is coming. Bariatric surgery
isn't cheap, but if its costs must be weighed against
a lifetime of diabetes therapy, it may prove surprisingly
good value.
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