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Medical Minute 8-24: Weight Loss Procedure Curing Diabetes

By: Vanessa Welch Email
By: Vanessa Welch Email

He was the personal chef for millionaire Donald Trump.

And now, Tom Haynes is responsible for bringing students into the Institute of Culinary Education.

"I've had the great pleasure of working with tens of thousands of students," said Tom Haynes, Chef.

But he's most proud of what he did for his health.

Weighing in at 285, Tom was diabetic for 10 years.

"I had to stab myself 13 times a day with insulin."

Today, Tom is insulin- and medication-free -- all because of a side effect of bariatric surgery.

"Some patients who take insulin for type 2, they have an operation, and very often, we don't put them back on insulin," said Francesco Rubino, M.D., New York-Presbyterian/Weill Cornell.

Doctor Francesco Rubino is spearheading the studies of gastric bypass surgery and its effects on type-two diabetes. It started back in 1999 when he noticed an unexpected side effect to the surgery he was performing on morbidly obese patients.

"I noticed some patients had diabetes remission as early as days or weeks after the operation."

Once a surgery only used for people with body mass indexes over 35, now a new clinical trial at New York-Presbyterian is using gastric bypass for people suffering from diabetes with BMI as low as 26.

"I thought changing the gut anatomy, you change the way the way the gut speaks to the body."

And the way the pancreas creates insulin, which doesn't work properly for people with type-two diabetes. But why this surgery sends diabetes into remission is still a mystery.

"It's totally changed my life."

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: According to the Mayo Clinic, gastric bypass is the most frequently performed bariatric surgery in the United States. Many surgeons prefer gastric bypass surgery because it generally has fewer complications than other weight loss surgeries. Gastric bypass surgery can provide long-term, consistent weight loss if the patient exercises and eats a healthy diet. The surgery combines the creation of a small stomach pouch to restrict food intake and construction of bypasses of the duodenum and other segments of the small intestine to cause malabsorption, which decreases the ability to absorb calories and nutrients from food.
BENEFITS: Extreme obesity affects nearly 24 million adults, which is nearly 6 percent of Americans. It is associated with more than 30 medical conditions, including type 2 diabetes, coronary heart disease, stroke, hypertension, sleep apnea, joint disease, and cancer. According to WebMD Health News, 89 percent of people with type 2 diabetes who underwent gastric bypass surgery went into remission, and 57 percent were still in remission after five years. The cost of treating diabetes is enormous. A person diagnosed at age 50 can expect to spend $172,000, which is the equivalent of seven gastric bypass procedures. Diabetes has disappeared in some patients almost immediately or within days of gastric bypass surgery. Blood sugar levels begin to fall soon after surgery, becoming completely normal within a year.

SURGERY AS DIABETES TREATMENT: The International Diabetes Federation, which represents more than 200 diabetes groups across the globe, called for weight loss surgery to be considered a treatment for type 2 diabetes in certain patients with body mass indexes (BMIs) as low as 30. Improvements in general health are also common after this surgery. Obesity-related medical conditions usually improve or even go away after gastric bypass surgery; including arthritis, obstructive sleep apnea, and high blood pressure. About 95 percent of people report improved quality of life after weight loss surgery. Some studies also suggest people live longer after weight loss surgery compared to equally obese people who do not have surgery. (SOURCE: http://www.idf.org/)

FOR MORE INFORMATION, PLEASE CONTACT:
Andrew Klein, Public Relations
New York-Presbyterian/Weill Cornell
Ank2017@med.cornell.edu

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THE FOLLOWING IS AN IN-DEPTH INTERVIEW WITH THE DOCTOR FROM THE STORY ABOVE:

Francesco Rubino, MD, New York-Presbyterian/Weill Cornell, talks about how bariatric surgery might help patients with type 2 diabetes.
We are talking about a fairly new surgery to help people with type II Diabetes.
Francesco Rubino: Well, it’s not necessarily the surgical procedure that is new it’s the idea that you should use surgery primarily to treat diabetes. This has become now more a concept that is widely accepted including the diabetes committee. Patients who have diabetes and also of course are obese they should be considered for a surgical option.
But the surgery is bariatric surgery, it’s just like what you would use for morbidly obese people?
Francesco Rubino: You could use certainly the conventional bariatric operation to treat patients with diabetes and of course there is much clinical investigation in trying to modify those procedures for certain patients particularly those with lower PMI levels.
How is it different for people with lower BMI?
Francesco Rubino: Well people with lower BMI could still benefit from conventional bariatric procedures. It’s not necessarily true that a lower BMI requires a different procedure. For instance a standard gastric bypass could be an excellent option for patients who are mildly obese for instance with diabetes.
Why does it even work for somebody with diabetes?
Francesco Rubino: Well it works well in reality we don’t know exactly what is the molecular explanation or if there is a particular hormone or another mechanism that explains why diabetes actually disappears in some patients. What we know for sure at this point I think is that it’s not just a matter of weight loss. It’s beyond weight loss there are many other potential mechanisms. We used to think that the organ that we operate on, the stomach and the intestine, is basically an endocrine organ. It’s an endocrine organ that controls and regulates insulin secretion, insulin action and many other aspects of the metabolism of sugar. So it’s not surprising that if you alter the anatomy of that organ you have an effect on diabetes.
How are you changing or testing it for people with lower than thirty five BMI, how do you change the surgery?
Francesco Rubino: Well today we have an agreement from all the major diabetes societies that patients with severe basic diabetes should be absolutely considered for a surgical option. The question under investigation is whether patients with lower body mass index with less degree of obesity should also be considered for surgery. In some cases this might be worthwhile especially if diabetes is poorly controlled and there is a number of other risk factors for cardiovascular disease, and even though the obesity may be mild to moderate so BMI over thirty. But for lower BMI patients we still don’t have enough information to understand whether surgery is preferable to conventional medical treatments. That’s why we need clinical trials and that’s why we’re doing one of them here at Weill Cornell.
The study that you’re doing here with people with lower BMI are you doing anything different than the traditional bariatric through?
Francesco Rubino: The study we have here at our center actually it’s a study were we use a conventional gastric bypass surgery for treating diabetes in patients who are overweight or just mildly obese. We already have information from previous studies that gastro bypass is well tolerated in these patients and can be also effective. Now we’re trying to compare gastric bypass to the optimal best valuable medical treatment to see whether not only is it effective but if it’s even preferable to available drugs.
In your study with patients with lower BMI is there any BMI that is too low that you would not use this?
Francesco Rubino: In the study that we are conducting here we have a BMI range between twenty six and thirty five. We’re not going for the moment for lower BMIs simply because we don’t understand yet if surgery is suitable for those patients. Not just because of concerns on their weight but more about concerns on the type of diabetes that those patients might have. We know for sure for instance that Type II diabetes is not a single disease, it’s a syndrome where there may be different forms of disease. And as you go down with the BMI you might encounter more often certain type of forms of diabetes that might not be the best to be treated surgically.
Are there any risks when you take someone of a normal weight and give them a gastric bypass?
Francesco Rubino: The reason why we’re using conventional gastro bypass in patients with lower BMI comes from the evidence that early studies where gastro bypass was used in the patients with low BMI, for instance in India, where patients had even BMI as low as twenty two have not shown the operation to induce excessive weight loss which may be a concern of course. Or other particular complication in addition to the ones that we already know. There’s another consideration that we have to make, gastro bypass is not a novel operation it’s been around for fifty years. But also it was invented as a surrogate type of anatomic procedure very similar to the ones that were used to treat ulcers or gastric cancer. We do gastrectomy, which is even more radical than gastric bypass, for gastric cancer or for peptic ulcer in patients whose BMI is much lower than what we are actually considering for our study. So we had data from other surgical experiences to suggest that gastro bypass is a reasonable option even for patients who are not morbidly obese.
Gastric bypass in the past sometimes is it like a temporary cure because when patients lose their lifestyle habits they can still become obese again, is it the same with diabetes?
Francesco Rubino: Well we have seen patients who have had weight regain with gastric bypass although the majority of them doesn’t necessarily have weight regain and we’ve see patients who have diabetes recurrence with weight regain. But we also saw patients with weight regain without diabetes recurrence so it’s not automatically associated, the regain of diabetes and excess weight. The risk of recurrence is always contemplated, every time we do a surgical operation whether we do it for hernia or for cancer or for diabetes we have to consider that there is a potential for disease recurrence. We have data from the bariatric experience suggesting that even twenty years after a surgical operation many patients who had initial remission of diabetes are still in remission. So yes there’s a risk of recurrence but there also is a substantial chance of having prolonged remission.
Is this a cure for diabetes?
Francesco Rubino: That’s the most difficult question to answer, I don’t think we are at a stage where we can claim victory, I don’t know if we have a cure. And the reason is because we don’t understand what is the cause of diabetes. So we can’t claim we are curing a disease if we don’t know what we’re doing to its causes. Having said that the fact that our patients who have had diabetes once in their lifetime, they got a surgical operation again once in their lifetime and twenty years later there is no evidence of diabetes. If it’s not a cure it’s the closest thing we have ever seen.
What’s the success rate?
Francesco Rubino: We technically have seen eighty percent of patients who have gastro bypass for morbid obesity with diabetes to enjoy a normalization of blood sugar levels. However, in those experiences what we called diabetes is a condition of mild to very severe diabetes so the remission rate may defer whether the diabetes has been around for too many years or if the patient is requiring high dosages of insulin for insulin deficiency or depending on other characteristics. So we can’t say each individual patient will have the chances of having diabetes remission. We can say that overall there is a greater than fifty, sixty percent of chances to get diabetes in to remission.
Why wouldn’t you just do this on everybody? It sound like it would be less expensive than supporting someone on diabetes and all the illness that comes with that.
Francesco Rubino: That is true, it is logical to expect that surgery would be more cost effective than treating diabetes with medication for a lifetime. And in fact all the studies that I have looked at on cost effectiveness have shown that gastro bypass and surgery in general is more cost effective than anything we have ever used to treat diabetes. But having said that I don’t think you can treat everybody with a surgical operation. To give you an example, if you think about any other disease that is conventionally treated by a surgical operation say gallbladder stones and gallbladder removal, for stones in their gallbladder. Thyroidectomy for thyroid nodules. There are four point eight percent of the population that have nodules in there thyroid you don’t operate on. You operate only when the condition causes a risk for life expectancy or for quality of life, etc, that cannot be addressed by other treatments. So when diabetes is mild it could be controlled by dieting, exercise or moderate drug therapy I think there is no compelling reason to have a surgical operation. But when this doesn’t happen you have no alternative but why not considering surgery. Today I think we have one more option I think this is good news for patients.
What are the risks?
Francesco Rubino: Well there are risks linked to the fact that these operations require general anesthesia and also there are risks, intrinsic risks, with the type of surgery that we perform. Of course surgery may have technical complications in the immediate postoperative time but also there are long term concerns particularly regarding nutrient absorption that require patients to be careful and aware that their vitamins or their iron, their nutrients need to be kept under control and supplemented with daily dosages of multivitamins. But having said that we have to recognize that bariatric surgery and gastric bypass are among the safest type of operations that we perform in general surgery today. The mortality risk of an operation like this is as low as gallbladder removal. For too many years bariatric surgery has been considered lethal or dangerous at the very least, simply because we did not as a medical community understand that this is not a cosmetic procedure it’s a lifesaving procedure. You would accept ten times of the risk of mortality of gastro bypass to the coronary artery bypass but you have not considered gastro bypass for many years in spite of the low mortality simply because it was considered an operation for obesity. That many patients and unfortunately too many doctors have not recognized it’s a true disease. That’s the way we’ve been conceptualized risks and benefits and I think now there is a better understanding of the benefits of gastro bypass, there’s a better understanding of the risk from obesity and from diabetes and I think we can weigh the risks and benefits in a much better way.
Now you’ve got to get the word out about this for diabetics and the Diabetes Association just gave this a great endorsement.
Francesco Rubino: I think it’s very important, awareness is one of the most important things. Many patients with diabetes don’t even know that surgery is an option for them. And recently the International Diabetes Federation, the worlds most authoritative diabetes organization that represent two hundred national diabetes societies has recognized the problem and the lack of awareness in the medical community about the benefits of bariatric surgery particularly for patients with diabetes. So there’s a strong recommendation today that patients who have both obesity and diabetes especially when diabetes is difficult to control those patients should be considered for surgery. Most physicians who see diabetic patients on a daily basis have never considered surgery an option. And today with this statement from the International Diabetes Federation surgery becomes an option in the algorithm if you will of diabetes management.
Does that mean that insurance companies are more likely to pay for it for diabetes?
Francesco Rubino: With the recent medical indication you would expect that insurance companies should cover for those who have potential benefits from diabetes. I think there’s still much work to do in terms of increasing awareness among physicians, among the public including among insurance carriers.
Why wouldn’t this work for Type I diabetes?
Francesco Rubino: Well we know that patients who have Type I diabetes and are also morbid obese they do benefit from surgery as well. They usually reduce their need for insulin and they have better glycemic control. We haven’t seen however in Type I diabetes the spectacular remission that we see in Type II. So we are inclined to think this is a therapy primarily for Type II diabetes. But of course we are investigating why surgery is so effective on diabetes and Type II diabetes and the lessons that we will learn from that process will tell us whether this type of operation or some other operations might potentially be used for Type I as well in the future.
Since you don’t really know why this works so well how did you figure out it worked at all?
Francesco Rubino: Well I personally got intrigued with the idea of immediate effect of surgery and diabetes in patients who have morbid obesity, when I started to get interested in this I think it was 1999. I noticed that some patients had diabetes remission as early as days or weeks after the operation and to me that was a striking evidence that something else than just weight loss could be at play. I also did not know much about diabetes and obesity myself I was a surgeon in training and so I think I wasn’t under the impression that weight was so important as most people believe. So I thought that by changing the gut anatomy you change the way the gut speaks to the pancreas. And we know that the gut speaks to the pancreas every day. So to me it was a logical consequence of the change in the anatomy that surgery imposes. The fact that you see diabetes getting better, much improved and so I investigated whether or not surgery could include diabetes per say as opposed to an effective weight loss and those experiments actually confirmed that there was an additional mechanism for action of surgery on diabetes that is not weight loss dependent. So based on that knowledge we’ve expanded our investigation and now we’re trying to understand if we can use this opportunity clinically to treat diabetes in those who have the disease but not necessarily are morbid obese.
So the people that are being treated with this are some of them insulin dependent?
Francesco Rubino: Some patients are using insulin in spite of the fact of having Type II diabetes and many patients who have Type II at some point in the history of their disease they will need some insulin to control their glycemia. Diabetes is a progressive disease where there is insulin resistance, Type II diabetes has a component of insulin resistance and a production of insulin from the pancreas that is not sufficient to cope with the resistance of the body to insulin. Over time the pancreas does not make enough insulin and at that point some patients may require taking insulin. So the fact of being on insulin doesn’t mean that you have Type I you may have Type II diabetes and require insulin.
So have you seen people on insulin or other medication and after this surgery within two weeks become completely medication and insulin free?
Francesco Rubino: Yes we have seen this very often, some patients who take insulin for Type II diabetes they come, they get an operation and very often we don’t even start insulin after surgery because we know that the glycemia improves so fast.
I’m talking to Tom tomorrow, what was he like before and after?
Francesco Rubino: He was a patient who had Type II diabetes requiring insulin and many other medications. And Tom experienced a typical remission of Type II diabetes where he was able to quickly reduce his medication requirement, stop with the insulin and progressively all other medications while his blood sugar levels became normal. So he not only improved glycemia but also improved a number of other metabolic alterations, blood pressure and cholesterol and triglycerides in particular, high triglycerides he had. So again he actually was able to stop not just anti-diabetic medication but many more medications he was taking.
Now you’re telling people they don’t have to deal with diabetes the rest of their life. That has to be pretty amazing for a lot of people.
Francesco Rubino: It is amazing and it will be sufficient to see one of these patients. First it’s Tom and see how difficult it was for him to struggle with diabetes before and how different his life is now. To be struck by this almost magic kind of effect that of course for a scientist, for a clinician it’s something that is a compelling reason to pursue further research to understand why this operation is so effective. Because if we do understand why gastro bypass works we might understand how diabetes works. And in the future we might not need an operation to treat or maybe even cure diabetes.


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