If you have diabetes, maybe you should have weight loss, or bariatric surgery. That's one conclusion of two new studies published this week in the New England Journal of Medicine, looking at two different types of surgery: gastric bypass or gastric sleeve. As I talk about in this week's YouTube, the gastric sleeve operation is a good deal less invasive, but isn't nearly as effective for either weight loss or diabetes control. Yet as Rick and I rather cynically conclude in this week's PodMed, the success of both types of surgery with regard to blood sugar control offers job security to those surgeons who perform these operations, as both obesity and diabetes skyrocket worldwide.
In one of the studies, 150 overweight or obese people with elevated hemoglobin A1c (HbA1c) levels were randomized to either intensive medical therapy alone or to medical therapy plus either a traditional gastric bypass operation or the less invasive gastric sleeve. In the second study 60 patients were randomized to medical therapy alone, or one of the two types of bariatric surgery. Both studies demonstrated benefits with regard to the need for medical therapy for glucose control. In the first study, 42% of patients who had gastric bypass surgery achieved a hemoglobin A1c level of 6.0% or less at 12 months of follow up, 37% of patients in the gastric sleeve group and 12% of the medical therapy alone group. In the second study 75% of those who had the gastric sleeve operation and 95% of those who had the gastric bypass had achieved remission of their diabetes.
Does this mean that people who have diabetes should consider such surgery for control of their blood sugar? Right now, those who wish to undergo either operation must meet eligibility criteria, including an elevated body mass index. But just how high does your BMI have to be in order to qualify for the operation, particularly when taken in conjunction with elevated HbA1c? That number seems to be dropping all the time.
Another consideration is the well-known impact diabetes has on long term health, including the risk of heart attack and stroke. Does the cost/benefit ratio tip in favor of bariatric surgery when substantial reduction of this risk is taken into account? It's interesting and noteworthy that both studies were presented at the American College of Cardiology meeting in Chicago this week. Clearly the cardiologists are also paying attention.
Finally, I was privileged to talk with Thomas Magnuson, bariatric surgeon extraordinaire at Johns Hopkins Bayview, a center of excellence for this type of surgery, about these studies. He reminded me that it was surgeons, nurses and other members of the health care team taking care of patients undergoing bariatric surgery who originally noted the dramatic reduction in blood sugar that takes place within days of the surgery, a real curiosity since it indicates that weight loss is clearly not the mechanism by which blood sugar is modified in people with diabetes. Since then much research has been stimulated on exactly what the pathway might be, and the relative success of gastric bypass versus gastric sleeve seems to support one hypothesis involving hormones produced in the stomach and small intestine. Research is ongoing, but perhaps will give rise to an better understanding of blood sugar control and the eventual development of a better way to control it, perhaps avoiding surgery altogether.
Other topics this week on PodMed, all from NEJM (!), include two studies looking at antibody treatments for psoriasis, a study looking at outcomes of bypass surgery versus stent placement for coronary artery disease, and the safety of stent placement at community hospitals. Until next week, y'all live well.