Treating Diabetes & Not the Number

DIABETES: TIME TO STOP “TREATING THE NUMBER” AND INSTEAD ACHIEVE A CURE?

Traditionally, modern medicine and the pharmaceutical industry have managed diabetes by treating the serum blood glucose number. Medications serve to bring the blood glucose number down to a more normal level, and that is believed to delay or prevent some of the complications of diabetes: kidney failure, blindness and artery disease that can lead to heart attacks and limb amputations.

Recent evidence, however, is persuading physicians and their patients to no longer be satisfied with this strategy of “treating the number” and many are seriously looking at curing the Type 2 diabetes altogether.

Diabetes afflicts 26 million Americans, and the numbers are rising dramatically. Ninety-five percent of people with diabetes suffer from Type 2 diabetes or what we used to call “adult onset” diabetes. This is the kind that is closely associated with weight gain and obesity. As we all know by now, the country is getting heavier, creating a dramatic epidemic of obesity and Type 2 diabetes that public health experts have coined “diabesity”. Alarmingly, an additional 75 million Americans have “pre-diabetes”, a condition which will often progress to full-blow diabetes if intervention is not undertaken.

But how to cure a metabolic condition that begins as a consequence of obesity? The answer, as reported in two widely discussed randomized controlled trials in the New England Journal of Medicine published in 2012, comes in the form of minimally invasive metabolic and bariatric surgery, what we commonly think of as weight-loss surgery.1

Weight-loss surgery has evolved quickly from a past era of large open abdominal incisions and worrisome complications to the present era of minimally invasive procedures with keyhole incisions that take less than an hour to perform and are safer than hernia and Ceasarian section procedures. The field changed its name to “metabolic and bariatric surgery” after recognition that gastric bypass surgery improved the body’s metabolism, quickly and permanently controlling the blood glucose –resolving diabetes. It was a rare breakthrough in diabetes care, an immediate cure to a chronic disease – and a philosophical departure from the concept of “treating the number”.

The two studies that recently achieved acclaim were examples of something rare in modern surgical treatment: randomized controlled trials. In measuring the true impact of surgery on diabetes, the patients learned whether or not they would undergo surgery by the result of a coin flip. In the trials in Europe and the United States, patients with diabetes were randomized by the flip of a coin to either undergo intensive medical management (“controlling the number” plus diet and weight management), or undergo a modern minimally invasive weight-loss surgical procedure. The results were stunning: the vast majority of patients undergoing the minimally invasive bariatric surgical procedures resolved their diabetes as measured by normal hemoglobin A1c levels and normal glucose levels while off medications entirely. Those in the non-surgical arms of the trials, predictably, did not resolve the condition, but continued to take both oral medications and insulin injections.

At one to two year follow-up, around 85% of the patients in the studies remain free of diabetes. Yet it is estimated that only 1-2% of people with Type 2 diabetes are currently availing themselves of this – the only modern treatment that may actually cure the disease. For an obese individual, the risks of not having surgery far exceed those of undergoing the procedure, based on a number of large studies that track mortality data for people with diabetes.3

Despite these data showing an 80%-plus cure rate with surgery, some fear that medical tradition and the economic interests of the pharmaceutical industry will conspire to preserve a culture of “treat the number” diabetes care. But as the most recent publications in the New England Journal of Medicine demonstrate, there can be little doubt of the effectiveness and safety of modern minimally invasive surgery to resolve diabetes, allowing individuals to stop taking medications and insulin injections.

Minimally invasive weight-loss procedures including the gastric bypass, the gastric sleeve procedure, and gastric banding are emerging as the standard treatment for Type 2 diabetes for individuals with a Body Mass Index over 30. Already, the American Heart Association and many other medical societies recommend the procedure as an option for their patients who are obese and diabetic.4 In time, as an accompanying editorial in the New England Journal of Medicine infers, we are likely to see far more individuals achieving a cure for their diabetes, rather than continuing to “treat the number”.

 

References:

1. Mingrone G et. al., Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes, New England Journal of Medicine 2012; 366: 1577-1585.

2. Schauer P et. al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes, New England Journal of Medicine 2012; 366: 1567-1576.

3. Christou N et. al., Surgery Decreases Long –Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients, Annals of Surgery 2004; 240(3): 416-424.

4. Poirier P et. al., Bariatric Surgery and cardiovascular risk factors: a scientific statement from the American Heart Association, Circulation 2011 April 19; 123(15): 1683-1701.