October 1, 2013

Study Quantifies Whether Weight Loss Surgery Cures Diabetes

A study recently published in the Annals of Surgery gives much more insight into oft-repeated claims that weight loss surgery cures diabetes.

The study can be found here:

Can Diabetes Be Surgically Cured? Long-Term Metabolic Effects of Bariatric Surgery in Obese Patients with Type 2 Diabetes Mellitus.   Brethauer, Stacy A. et al. Annals of Sugery, 10/13/2013. doi: 10.1097/SLA.0b013e3182a5034b

The study followed  217 people with Type 2 Diabetes who had had weight loss surgery for a period lasting between 5 and 9 years. One hundred and sixty-two had the radical Roux-en-Y gastric bypass operation, which irreversibly reroutes the path of food through the stomach and small intestine. Thirty-two had the potentially reversible gastric banding procedure where a band limits the site of the stomach, and 23 had the irreversible amputation of part of the stomach sleeve known as sleeve gastrectomy.

Complete remission--i.e. a cure--was defined as the patient having an A1C less than 6% and a fasting blood glucose less than 100 mg/dL while taking no diabetic medications.

It is worth noting that many people with Type 2 are able to achieve these same numbers by cutting down their carbohydrate intake, without exposing themselves to any of the significant long-term risks that come with these major surgical interventions.

The Long Term Results

Only 24% of those who had these surgeries met the definition of "complete remission." This, of course, means that 76% still had abnormal blood sugars.

Thirty-four percent were described as having "improved." The study defined "improvemetn" as meaning that the subjects experienced a drop in A1c greater than 1%. Since the starting A1cs of the subjects in this study ranged up to 8.5%, a person could be considered "improved" if their A1c six years after surgery was still 7.25%--a level corresponding to an average blood sugar of 162 mg/dl (9 mmol/L). That is a level high enough to cause all the classic diabetic complications and it correlates with a greatly increased risk of heart attack.

But it gets worse. A full 16% of those who had these major surgeries--one out of 6--saw no improvement at all in their blood sugars.

And even more depressing for people who had these expensive, dangerous surgeries, of those whose blood sugars normalized right after surgery, 19% saw their blood sugars go back up into the diabetic range.

The authors of the study describe these results as being wonderful news showing that "Bariatric surgery can induce a significant and sustainable remission" in people with Type 2 Diabetes.

The statistics above suggest that the improvements caused by these surgeries are almost entirely due to the fact that they make it impossible--at least for a short time after surgery--for people who have rearranged their stomaches to eat any significant amount of the carbohydrate-rich foods that raise the blood sugar of people with diabetes.

As time goes by people who have had some of these procedures will have their stomachs stretch out again and will once again be able to eat the high carbohydrate foods that raise blood sugars, explaining the failure that often occurs in people who at first appeared succesesful.

This is because most people with Type 2, even those with very high A1cs will see dramatic drops in their blood sugars within a week or two if they cut back dramatically on their carbohydrate intake--whether they do this by limiting their stomach size or changing what they keep in the refrigerator.

Those who don't see a drop in their blood sugars after restricting carbohydrates usually turn out to have a problem secreting insulin. If they have this kind of surgery they are likely to end up in that unfortunate 16% who get no benefit from it at all. In fact, what they need is not surgery, it's often an appropriately prescribed insulin regimen.

But sadly, rarely do surgeons or the doctors who refer people for this surgery do the tests that could determine if people are insulin deficient and hence unlikely to benefit from this kind of surgery.

Finally, it is interesting that there is no hint here to confirm the latest, most fashionable explanation for why weight loss surgery works--that rearranging the gut boosts incretin hormones and lowers blood sugar independent of carbohydrate intake.

Why No Mention of the Complication Rate? 

A far worse omission, however, is that this study omits any mention of the surgical complications these people could have suffered as a result of undergoing these major invasive surgeries. Quite a few studies have found that the rate of post-operative complications associated with these surgeries is between 7 and 9%--almost one in ten.

Serious complications--such as incisions opening-occur in roughly 3.5%--one in 29--and one in a hundred patients require additional surgeries.  (Details HERE and HERE) Even more tragic, large epidemiological studies find that something like .18% of patients who have these surgeries die. That is almost two per thousand. Given that it is estimated that 205,000 people a year have weight loss surgery, this works out to about 400 deaths each year due entirly to elective bariatric surgery.

And these complication statistics include only the deaths and complications that occur shortly after surgery. They ignore the ongoing health problems that many people suffer after having supposedly "successful" surgeries.

These problems include permanent malnutrition due to the loss of the gut's ability to absorb vital minerals and mental changes which can lead to fatal anorexia or an increased incidence of suicide. I have heard from several people whose relatives died from the anorexia and malnutrition caused by having had this kind of surgery. It is a real problem which probably has something to do with changes the surgery makes in the gut hormones that regulate appetite and feeding behavior in the brain.

Consider the Alternatives

So before you sign up for this questionable diabetes cure, it's worth checking out the alternatives. Because the surgeons selling these expensive surgeries don't tell you that the majority of people with Type 2 diabetes can achieve the exact same kind long term results as are depicted in this study--or better--without resorting to surgery. They can do it simply by following the technique described here:

How to Lower Your Blood Sugar

It is carbohydrates that raise blood sugar, and cutting back on them will lower the blood sugar of most people with Type 2 Diabetes.

But despite this being true, many people who are told that they can lower their blood sugar permanently by cutting down on their carbohydrate intake dismiss this idea saying, "I could never stop eating the high carb foods I love."

If you fall into that category and would prefer a surgical approach, it's worth considering that any weight loss surgery that lowers your blood sugar will force you to give up those high carb foods forever.  When your stomach is shrunken to where you can only eat 1000 or so calories a day, it is physically impossible to eat a lot of carbohydrates .And in many cases--often those who are most "successful" with both weight loss and blood sugar control, the changes the surgery makes in your digestive tract ensure that high carbohydrate foods will cause projectile vomiting--an experience that will quickly train you to avoid the foods that could raise your blood sugar no matter how you used to feel about them.

Personally, I'd prefer to lower my blood sugar using a technique that doesn't expose me to the risk of death or permanent malnutrition and that allows me an occasional indulgence in ordinary foods. I also prefer an approach that doesn't permanently rearrange my organs and which leaves open the possibility that I might be able to benefit from some less radical future advance in the control of Type 2 diabetes.

There is a lot of money in selling these surgeries. And as everyone with diabetes knows, it is the money to be made that drives what treatments we are directed to. Surgeons market their surgeries to your family doctors just as much as the drug companies market their latest, most expensive, and most dangerous drugs.  I hear from quite a few people whose family doctors have told them to have these surgeries--without ever suggesting carb restricted diets or doing the tests needed to determine if the person needs insulin.

But armed with the facts like those that came out of this study, you will be better prepared to defend yourself against inappropriate and potentially harmful treatments.

One last note: It continues to amaze me that the same physicians who continue to issue dire warnings about how dangerous low carb diets are to your health are the same people who recommend these far more dangerous surgeries.

When researching my book Diet 101: The Truth about Low Carb Diets I was able to find a grand total of 2 verified reports of deaths that could be linked in any way with low carb dieting--and they were linked with starvation diets that were dangerous not because of their low carbohydrate intake but because of their lack of calories and electrolytes. Compare this with those 400 deaths a year attributable to these surgeries!