By Dr. Kate Scannell, Syndicated columnist; First Published in Print: 03/31/2012
Two studies published in last week's New England Journal of Medicine generated much media attention and hope that maybe, just maybe, a swift surgical fix could cure two notoriously chronic and intertwined medical conditions that affect millions of people worldwide: obesity and Type 2 diabetes. But it would be wise -- and healthy -- to scale back any unbridled enthusiasm about that until many more facts weigh in.
In both studies, researchers set out to answer whether weight-loss surgeries -- also known as bariatric surgeries -- could help manage blood-sugar control in obese Type 2 diabetics. As is well-known, standard medical treatment of Type 2 diabetes with pills and insulin often promotes additional weight gain, and a vicious cycle is set into motion: The additional weight gain worsens blood-sugar control, calling for additional diabetes medications that lead to more weight gain, which worsens the diabetes, which calls for more medication, which ...
But suppose, the researchers speculated, we interrupt this crazy cycle with weight-loss surgery? The lowered body weight might naturally lead to lower blood-sugar levels which, in turn, would require less of the diabetes medication that encourages weight gain?
The bottom line is that both studies showed some benefit in controlling blood sugars for some patients who underwent weight-loss surgeries -- either a "sleeve gastrectomy," which physically limits the amount of food the stomach can take in, or an abdominal-bypass operation that thwarts the body's absorption of food from the gut. Many headlines and reports breathlessly heralded this finding as evidence that surgery might cure diabetes or force it into remission.
However, controlling blood tests for sugar is not the same thing as controlling or curing a person's diabetes. In fact, we know that serious complications from diabetes -- such as heart and kidney diseases, neuropathy and retinal disorders -- can progress all the while that a diabetic might maintain excellent test results for blood sugar.
It is extremely disappointing that neither group of researchers opted to design their studies to test whether surgical interventions actually improved patients' health and reduced their complications from diabetes. Really, shouldn't that -- and not a blood-test result -- be the research focus?
It's also important to note that both studies compared outcomes of weight-loss surgery against a control group of diabetics receiving standard medical therapy with pills, insulin, and routine advice about weight-loss and exercise. A more genuine comparison would have used a control group receiving medical weight-loss therapy.
Both studies also limited their post-surgical follow-up of patients to short time intervals -- a mere 12 months in the larger American study, and only two years in the smaller Italian study. That's critical because 12 to 24 months is too short a time to determine whether any success at controlling blood sugar was truly lasting -- especially since we know that most patients regain some weight after bariatric surgeries. It's also too brief an interval to discover whether the surgeries might affect the incidence or severity of diabetic complications such as heart or kidney diseases, which typically take years to develop.
And before we start routinely recommending costly, invasive surgeries that incur some risk of morbidity and mortality for the 20 million U.S. patients with Type 2 diabetes, let's take a deep breath and remember that, collectively, both studies involved a mere total of 139 diabetic patients who received surgery. Of those 139 surgical patients, only 73 people achieved normalization of their blood tests after surgery -- 66 others did not.
Now take a deeper breath and consider this: The larger American study, which accounted for 99 of those 139 surgeries, was funded by Ethicon Endo-Surgery -- the manufacturer of the expensive surgical equipment used by the researchers. Furthermore, the American study's lead author was a surgeon who not only had received consulting and lecture fees from Ethicon, but also payments for being a member of that company's board. If that doesn't raise an eyebrow for you, consider that he also performed all the surgeries himself.
An accompanying editorial in the New England Journal of Medicine at least acknowledges that both studies involved too few people for too short a time to allow us to determine whether weight-loss surgery could be "the universal panacea for obese patients with Type 2 diabetes." And yet, its two authors -- noted diabetes experts -- clearly nudge us toward thinking otherwise, and they fan the flames of misleading media hype. For example, they declare that the two studies are "likely to have a major effect on future diabetes treatment." And while wisely calling for additional research, they also argue: "Meanwhile, the success of various types of bariatric surgery suggests that they should not be seen as a last resort. Such procedures might well be considered earlier in the treatment of obese patients with Type 2 diabetes."
Both editorialists -- before the new studies were even published -- had made authoritative public comments recommending weight-loss surgery as treatment for obese Type 2 diabetics. For example, as heads of the influential International Diabetes Federation Taskforce on Epidemiology and Prevention that convened in 2010 -- at a meeting partly funded by Ethicon -- they issued this formal advisement in early 2011: That weight-loss surgery was "an effective, safe and cost-effective therapy for obese Type 2 diabetes."
Clearly, interests other than science are shaping the health care landscape and media reporting about medical research. Unfortunately, we can't perform bariatric surgery on the entire medical-industrial complex to reduce its unhealthy weight of these biased interests. Meanwhile, it's simply impossible to know whether weight-loss surgeries will actually help or harm Type 2 diabetics in the long run.
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Kate Scannell is a Bay Area physician and syndicated columnist.
© Copyright 2012, Kate Scannell
Two studies published in last week's New England Journal of Medicine generated much media attention and hope that maybe, just maybe, a swift surgical fix could cure two notoriously chronic and intertwined medical conditions that affect millions of people worldwide: obesity and Type 2 diabetes. But it would be wise -- and healthy -- to scale back any unbridled enthusiasm about that until many more facts weigh in.
In both studies, researchers set out to answer whether weight-loss surgeries -- also known as bariatric surgeries -- could help manage blood-sugar control in obese Type 2 diabetics. As is well-known, standard medical treatment of Type 2 diabetes with pills and insulin often promotes additional weight gain, and a vicious cycle is set into motion: The additional weight gain worsens blood-sugar control, calling for additional diabetes medications that lead to more weight gain, which worsens the diabetes, which calls for more medication, which ...
But suppose, the researchers speculated, we interrupt this crazy cycle with weight-loss surgery? The lowered body weight might naturally lead to lower blood-sugar levels which, in turn, would require less of the diabetes medication that encourages weight gain?
The bottom line is that both studies showed some benefit in controlling blood sugars for some patients who underwent weight-loss surgeries -- either a "sleeve gastrectomy," which physically limits the amount of food the stomach can take in, or an abdominal-bypass operation that thwarts the body's absorption of food from the gut. Many headlines and reports breathlessly heralded this finding as evidence that surgery might cure diabetes or force it into remission.
However, controlling blood tests for sugar is not the same thing as controlling or curing a person's diabetes. In fact, we know that serious complications from diabetes -- such as heart and kidney diseases, neuropathy and retinal disorders -- can progress all the while that a diabetic might maintain excellent test results for blood sugar.
It is extremely disappointing that neither group of researchers opted to design their studies to test whether surgical interventions actually improved patients' health and reduced their complications from diabetes. Really, shouldn't that -- and not a blood-test result -- be the research focus?
It's also important to note that both studies compared outcomes of weight-loss surgery against a control group of diabetics receiving standard medical therapy with pills, insulin, and routine advice about weight-loss and exercise. A more genuine comparison would have used a control group receiving medical weight-loss therapy.
Both studies also limited their post-surgical follow-up of patients to short time intervals -- a mere 12 months in the larger American study, and only two years in the smaller Italian study. That's critical because 12 to 24 months is too short a time to determine whether any success at controlling blood sugar was truly lasting -- especially since we know that most patients regain some weight after bariatric surgeries. It's also too brief an interval to discover whether the surgeries might affect the incidence or severity of diabetic complications such as heart or kidney diseases, which typically take years to develop.
And before we start routinely recommending costly, invasive surgeries that incur some risk of morbidity and mortality for the 20 million U.S. patients with Type 2 diabetes, let's take a deep breath and remember that, collectively, both studies involved a mere total of 139 diabetic patients who received surgery. Of those 139 surgical patients, only 73 people achieved normalization of their blood tests after surgery -- 66 others did not.
Now take a deeper breath and consider this: The larger American study, which accounted for 99 of those 139 surgeries, was funded by Ethicon Endo-Surgery -- the manufacturer of the expensive surgical equipment used by the researchers. Furthermore, the American study's lead author was a surgeon who not only had received consulting and lecture fees from Ethicon, but also payments for being a member of that company's board. If that doesn't raise an eyebrow for you, consider that he also performed all the surgeries himself.
An accompanying editorial in the New England Journal of Medicine at least acknowledges that both studies involved too few people for too short a time to allow us to determine whether weight-loss surgery could be "the universal panacea for obese patients with Type 2 diabetes." And yet, its two authors -- noted diabetes experts -- clearly nudge us toward thinking otherwise, and they fan the flames of misleading media hype. For example, they declare that the two studies are "likely to have a major effect on future diabetes treatment." And while wisely calling for additional research, they also argue: "Meanwhile, the success of various types of bariatric surgery suggests that they should not be seen as a last resort. Such procedures might well be considered earlier in the treatment of obese patients with Type 2 diabetes."
Both editorialists -- before the new studies were even published -- had made authoritative public comments recommending weight-loss surgery as treatment for obese Type 2 diabetics. For example, as heads of the influential International Diabetes Federation Taskforce on Epidemiology and Prevention that convened in 2010 -- at a meeting partly funded by Ethicon -- they issued this formal advisement in early 2011: That weight-loss surgery was "an effective, safe and cost-effective therapy for obese Type 2 diabetes."
Clearly, interests other than science are shaping the health care landscape and media reporting about medical research. Unfortunately, we can't perform bariatric surgery on the entire medical-industrial complex to reduce its unhealthy weight of these biased interests. Meanwhile, it's simply impossible to know whether weight-loss surgeries will actually help or harm Type 2 diabetics in the long run.
-----------------------------------------------------------------------
Kate Scannell is a Bay Area physician and syndicated columnist.
© Copyright 2012, Kate Scannell