{"id":416,"date":"2013-11-19T18:18:34","date_gmt":"2013-11-19T07:18:34","guid":{"rendered":"http:\/\/blog.panicola.com\/?p=416"},"modified":"2013-11-19T18:18:58","modified_gmt":"2013-11-19T07:18:58","slug":"forbes-curing-type-2-diabetes-with-surgery-it-works-now-lets-figure-out-why","status":"publish","type":"post","link":"https:\/\/blog.panicola.com\/?p=416","title":{"rendered":"Forbes: Curing Type 2 Diabetes with Surgery: It Works &#8212; Now Let&#8217;s Figure Out Why"},"content":{"rendered":"<ul>\n<li>Insulin resistance stabilises ahead of weight loss in gastric bypass surgery<\/li>\n<li>Insulin resistance tracks with weight loss in lap band surgery<\/li>\n<li>No one knows why, though some pharma start ups are looking for a molecule<\/li>\n<li>A great example of empiricism triumphing over reductionism<\/li>\n<\/ul>\n<p>PN: This still leaves the door open to the solid food hypothesis<\/p>\n<p>http:\/\/www.forbes.com\/sites\/davidshaywitz\/2012\/03\/26\/curing-diabetes-with-surgery-it-works-now-lets-figure-out-why\/<\/p>\n<div>\n<hgroup>\n<h5><a href=\"http:\/\/www.forbes.com\/healthcare\"><span style=\"font-size: 0.857142857rem; line-height: 1.846153846; color: #444444;\">3\/26\/2012 @ 11:59PM\u00a0|29,806 views<\/span><\/a><\/h5>\n<\/hgroup>\n<p><strong>Curing Type 2 Diabetes with Surgery: It Works &#8212; Now Let&#8217;s Figure Out Why<\/strong><\/p>\n<\/div>\n<div id=\"leftRail\">\n<div>\n<div>\n<p><span style=\"line-height: 1.714285714; font-size: 1rem;\">During my endocrinology training, I was captivated by a phenomenon I\u2019d seen on the wards, and had just started to read about in the literature: type 2 diabetic patients receiving bariatric surgery exhibiting rapid, seemingly instantaneous improvements in their glycemic control, apparently related to profoundly reduced insulin resistance as a consequence of the surgery.<\/span><\/p>\n<\/div>\n<p>The first teaching seminar I gave as a fellow, at Endocrinology Grand Rounds, asked the distinguished medical faculty who gathered in the Ether Dome, \u201cIs Diabetes a Surgical Disease?\u201d<\/p>\n<p>At the time, the answer was, \u201cYes?\u201d\u00a0 Now, two recent reports presented today at the ACC, and simultaneously published in the\u00a0<em>NEJM\u00a0<\/em>(<a href=\"http:\/\/www.nejm.org\/action\/clickThrough?id=3285&amp;url=%2Fdoi%2Ffull%2F10.1056%2FNEJMoa1200225%3Fquery%3Dfeatured_home&amp;loc=%2F\">here<\/a>\u00a0and\u00a0<a href=\"http:\/\/www.nejm.org\/action\/clickThrough?id=3285&amp;url=%2Fdoi%2Ffull%2F10.1056%2FNEJMoa1200111%3Fquery%3Dfeatured_home&amp;loc=%2F\">here<\/a>), seem to upgrade this answer to \u201cYes!\u201d<\/p>\n<p>Both reports conclude that bariatric surgery surpasses medical therapy as a treatment for type 2 diabetes, and are fascinating not only because of the immediate clinical implications (as discussed by Matt Herper\u00a0<a href=\"http:\/\/www.forbes.com\/sites\/matthewherper\/2012\/03\/26\/two-studies-show-obesity-surgery-can-reverse-diabetes\/\">here<\/a>,\u00a0and in an<em>NEJM\u00a0<\/em>editorial comment\u00a0<a href=\"http:\/\/www.nejm.org\/action\/clickThrough?id=3285&amp;url=%2Fdoi%2Ffull%2F10.1056%2FNEJMe1202443%3Fquery%3Dfeatured_home&amp;loc=%2F\">here<\/a>), but also because there\u2019s some really cool underlying science that nobody seems to understand.<\/p>\n<p>The fundamental paradox is the same mysterious clinical phenomenon that so intrigued me years ago: the drastic improvement in diabetic function that occurs significantly before most of the weight is lost.<\/p>\n<p>The authors of the first study note, \u201cReductions in the use of diabetes medications occurred before achievement of maximal weight loss, which supports the concept that the mechanisms of improvement in diabetes involve physiologic effects in addition to weight loss, probably related to alterations in gut hormones.\u201d<\/p>\n<p>The authors of the second study were also struck by the rapid improvement in glycemic control they observed, reporting that all patients treated surgically were able to discontinue all their diabetes medicines within fifteen days of their operation \u2013 a remarkable result (and entirely consistent with my own clinical experience).\u00a0 Almost all of the surgically-treated patients remained free of diabetes after two years, while none of the medically-treated patients were as fortunate.<\/p>\n<p>As the authors write, \u201cthere was no correlation between normalization of fasting glucose levels and weight loss after gastric bypass and biliopancreatic diversion, findings that are consistent with results of previous studies, which suggests that such surgeries may exert effects on diabetes that are independent of weight.\u201d<\/p>\n<p>The authors also point out this result is in contrast with gastric banding procedures (which constrict the stomach but don\u2019t otherwise alter the anatomy); the improvement in diabetes seen in those patients does appear to correlate more directly with weight loss.<\/p>\n<p>The intriguing scientific question is how can bariatric surgery result in an almost immediate improvement in the insulin resistance profile of diabetic patients?\u00a0 To my mind, this is among the most important unanswered questions in endocrinology, and medical science more generally.\u00a0 While the effect is generally attributed to \u201cgut hormones\u201d (as the authors of the first study write), the biology beyond that gets a bit murky.<\/p>\n<p>To be sure, some companies are working on it \u2013 the example that springs first to mind is\u00a0<a href=\"http:\/\/www.ngmbio.com\/\">NGM Biopharmaceuticals<\/a>, a small Bay-area biotech (with which I have no personal nor professional connection) founded in 2008 as an ambitious science play by The Column Group, Rho Ventures, and Prospect Venture Partners.\u00a0 I\u2019m sure others are working on this challenge as well.<\/p>\n<p>A final point \u2013 as attracted as we are to the view of basic science driving clinical medicine, the experience with gastric bypass surgery arguably exemplifies the reverse, and represents a triumph of empiricism, as well as a reminder of the value of human physiology (see\u00a0<a href=\"http:\/\/www.forbes.com\/sites\/davidshaywitz\/2011\/09\/23\/medicines-next-great-challenge-returning-science-to-the-patient\/\" target=\"_blank\">here<\/a>), and more generally, the importance of studying people (and not just parts of people).<\/p>\n<p>It also would not be the first (nor will it be the last) time that medical sophisticates learned a valuable lessons from those laboring \u2013 often, as in the case of many bariatric surgeons, with inadequate respect \u2013 on the front lines of patient care.<\/p>\n<div><img decoding=\"async\" alt=\"\" src=\"http:\/\/img.zemanta.com\/pixy.gif?x-id=fcc95b7f-eeb4-485f-a7ad-2f669a6e0655\" \/><b style=\"font-size: 1rem; line-height: 1;\">This article is available online at:\u00a0<\/b><\/div>\n<\/div>\n<div><b><a href=\"http:\/\/www.forbes.com\/sites\/davidshaywitz\/2012\/03\/26\/curing-diabetes-with-surgery-it-works-now-lets-figure-out-why\/\">http:\/\/www.forbes.com\/sites\/davidshaywitz\/2012\/03\/26\/curing-diabetes-with-surgery-it-works-now-lets-figure-out-why\/<\/a><\/b><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Insulin resistance stabilises ahead of weight loss in gastric bypass surgery Insulin resistance tracks with weight loss in lap band surgery No one knows why, though some pharma start ups are looking for a molecule A great example of empiricism triumphing over reductionism PN: This still leaves the door open to the solid food hypothesis &hellip; <a href=\"https:\/\/blog.panicola.com\/?p=416\" class=\"more-link\">Continue reading <span class=\"screen-reader-text\">Forbes: Curing Type 2 Diabetes with Surgery: It Works &#8212; Now Let&#8217;s Figure Out Why<\/span> <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9,13,22,3,20],"tags":[],"class_list":["post-416","post","type-post","status-publish","format-standard","hentry","category-healthcare","category-nutrition","category-policy","category-rapid-learning-health-systems","category-research-methodology"],"_links":{"self":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/416","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=416"}],"version-history":[{"count":2,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/416\/revisions"}],"predecessor-version":[{"id":418,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=\/wp\/v2\/posts\/416\/revisions\/418"}],"wp:attachment":[{"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=416"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=416"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blog.panicola.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=416"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}