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Monday, August 27, 2012

Diabetes: Is It Now a Surgical Disease?

Hi. I'm Dr. Henry Black. I'm Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at that institution, and former President of the American Society of Hypertension. If I had said 10 years ago that diabetes was going to become a surgical disease, I think I would have been laughed off the stage; yet, increasing evidence shows that this may not be a completely far-out idea. Two very small but important studies were recently published in the New England Journal of Medicine, one from the Cleveland Clinic[1] and one from Italy.[2] Both of them looked at people with high body mass index (BMI). BMIs were somewhat lower in the Cleveland Clinic study, with an average of about 34; in the Italian study, the average BMI was 45 and the average weight was about 300 lb. The investigators compared intensive medical therapy given by experts with surgical approaches. The Cleveland study looked at sleeve gastrectomies and bypass, and the Italian study compared intensive medical therapy (including exercise, which wasn't specifically done in the Cleveland Clinic study) with ileojejunostomy and bypass.

The results were strikingly similar. These were small studies; there were about 20 patients per group in the Italian study and about 50 per group in the Cleveland Clinic study. They both showed dramatic reductions in weight that were generally seen within 3 months. Patients were followed for 1 year in Cleveland and 2 years in the Italian study, and a significant improvement in all the metabolic parameters that we follow in diabetics -- including lipids, hemoglobin A1c, and even blood pressure -- happened before the weight loss was completely achieved. Patients with jejunostomy and bypass were able to be taken off diabetic medicines and, in some cases, lipid-lowering therapy, something that was never seen in patients who received only medical therapy.

This implies that we have to start thinking about using one of these techniques sooner until we can find a way to deliver behavioral therapy that people will follow.
It is a disease of fat people.

And as to the surgery?

If the fat want to pay for it out of pocket, slice 'em.

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