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Type 2 Revolution?
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One doctor wants us to know: bariatric surgery may cause remission of type 2
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By John McIntosh
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Diabetes Focus Winter 2008
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 | Michael A. Snyder, M.D., is a board-certified surgeon and director of the Denver Center for Bariatric Surgery and an active member of the American Society for Bariatric Surgery (ASBS).
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Among obese people with type 2 diabetes, 70 to 84 percent who undergo bariatric surgery—either laparoscopic gastric band or gastric bypass—experience a remission of their disease, according to studies cited in JAMA. And it's not just because of the weight loss caused by the surgery. Here, we explore this medical mystery with Michael A. Snyder, M.D.
One of the things I say to doctors at medical conferences—and I speak at them all around the country—is that type 2 diabetes is very difficult to treat, but it may be easier to cure. I say that as kind of a wake-up call, for people to pay attention to the importance of this treatment. It does seem to work.
In October 2004 in JAMA (the Journal of the American Medical Association), researchers reported on their review of studies of some 22,000 obese patients who underwent bariatric surgery. Seventy-seven percent of those with type 2 diabetes had a complete reversal of the disease. These studies also showed that bariatric surgery resolved or improved high cholesterol, hypertension and sleep apnea in a substantial majority of patients with these conditions. Then, early this year, an editorial in JAMA cited research showing that 84 percent of diabetes patients who had gastric bypass surgery experienced a complete reversal of type 2 diabetes. And a study in the same issue showed that 73 percent of diabetes patients who had laparoscopic gastric band surgery achieved remission of their disease, versus only 13 percent of those in the medical treatment group. Those numbers match our program’s findings. And it may not not be simply the weight loss that ends type 2 following these procedures. It may be something else.
We’re not really sure how these surgeries affect the endocrine system, but we know that they do and that they work. Many of us believe that there is something that sensitizes the pancreas, increasing either the number of beta cells that produce insulin or the ability of the beta cells to produce the hormone. More research is needed to determine this.
If you look at the data—including findings from this year’s JAMA study—physical management of type 2 doesn’t add up to significant weight loss. And weight loss doesn’t necessarily lead to the abatement of type 2.
In my program, following gastric bypass surgery, 67 percent of people with type 2 experience remission and 23 percent are significantly improved. With the laparoscopic gastric band procedure, 73 percent go into remission, and that number matches the JAMA findings.
Bariatric surgery is like any other invasive procedure. Age and blood pressure, for example, can be problems. With laparoscopic gastric band and gastric bypass, the actual surgical risks are typically minimal if the surgery takes place in a Bariatric Surgery Center of Excellence. Patients should only have them done in such a facility.
Seventy percent of the 21 million people who have type 2 diabetes in the United States and whose disease is associated with weight problems could potentially be cured by bariatric surgery. Another 20 percent of those with type 2 would experience noted improvement.
The surgeries aren’t appropriate for everyone. Obesity is defined by the National Institutes of Health as a body mass index (BMI) of 30 or greater. If your BMI is more than 35, you are a candidate for bariatric surgery. I’d like to see that bar lowered. The University of Campinas in Brazil is currently recruiting patients with BMIs between 30 and 34 for a clinical trial to examine whether classical bariatric surgery improves or reverses diabetes in these patients. If successful, many people who have a BMI of 30 to 34 could potentially benefit.
• Gastric bypass In this procedure, a small pouch is created out of
the top of the stomach then reattached to a bypass limb of the small
intestine. You digest food as before, but fewer calories and nutrients
can be ingested and absorbed. You eat less because the small pouch is
smaller than your stomach used to be.
• Laparoscopic adjustable gastric banding Two medical devices—a
silicone band and an injection port—are implanted to create a smaller
stomach. The silicone band is placed around the upper part of the
stomach and molds the stomach into two connected chambers. The
injection port is slipped under the skin and attached to the abdominal
wall; it’s connected to the band with soft, thin tubing. The band is
adjustable: Saline is added to or removed from the band via a needle
that goes into the port, increasing or decreasing the amount of
restriction provided by the band. Gastric banding requires more
intensive follow-up care, even after reaching and maintaining your
success weight.
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