[BlueSky]

There has been a lot of debate about this recently, and I thought this article would be of interest. If you are T2 and considering bariatric surgery, it looks like gastric bypass may be the way to go.

Type 2 Diabetes May Be Caused by Intestinal Dysfunction
Growing evidence shows that surgery may effectively cure Type 2 diabetes -- an approach that not only may change the way the disease is treated, but that introduces a new way of thinking about diabetes.

A new article -- published in a special supplement to the February issue of Diabetes Care by a leading expert in the emerging field of diabetes surgery -- points to the small bowel as the possible site of critical mechanisms for the development of diabetes.

The study's author, Dr. Francesco Rubino of NewYork-Presbyterian Hospital/Weill Cornell Medical Center, presents scientific evidence on the mechanisms of diabetes control after surgery. Clinical studies have shown that procedures that simply restrict the stomach's size (i.e., gastric banding) improve diabetes only by inducing massive weight loss. By studying diabetes in animals, Dr. Rubino was the first to provide scientific evidence that gastrointestinal bypass operations involving rerouting the gastrointestinal tract (i.e., gastric bypass) can cause diabetes remission independently of any weight loss, and even in subjects that are not obese.

"By answering the question of how diabetes surgery works, we may be answering the question of how diabetes itself works," says Dr. Rubino, who is a professor in the Department of Surgery at Weill Cornell Medical College and chief of gastrointestinal metabolic surgery at NewYork-Presbyterian/Weill Cornell.

Dr. Rubino's prior research has shown that the primary mechanisms by which gastrointestinal bypass procedures control diabetes specifically rely on the bypass of the upper small intestine -- the duodenum and jejunum. This is a key finding that may point to the origins of diabetes.

"When we bypass the duodenum and jejunum, we are bypassing what may be the source of the problem," says Dr. Rubino. In fact, it has become increasingly evident that the gastrointestinal tract plays an important role in energy regulation, and that many gut hormones are involved in the regulation of sugar metabolism. "It should not surprise anyone that surgically altering the bowel's anatomy affects the mechanisms that regulate blood sugar levels, eventually influencing diabetes," Dr. Rubino says.

While other gastrointestinal operations may cure diabetes as an effect of changes that improve blood sugar levels, Dr. Rubino's research findings in animals show that procedures based on a bypass of the upper intestine may work instead by reversing abnormalities of blood glucose regulation.

In fact, bypass of the upper small intestine does not improve the ability of the body to regulate blood sugar levels. "When performed in subjects who are not diabetic, the bypass of the upper intestine may even impair the mechanisms that regulate blood levels of glucose. In striking contrast, when nutrients' passage is diverted from the upper intestine of diabetic patients, diabetes resolves.

This, he explains, implies that the upper intestine of diabetic patients may be the site where an abnormal signal is produced, causing, or at least favoring, the development of the disease.

How exactly the upper intestine is dysfunctional remains to be seen. Dr. Rubino proposes an original explanation known in the scientific community as the "anti-incretin theory."

Incretins are gastrointestinal hormones, produced in response to the transit of nutrients, that boost insulin production. Because an excess of insulin can determine hypoglycemia (extremely low levels of blood sugar) -- a life-threatening condition -- Dr. Rubino speculates that the body has a counter-regulatory mechanism (or "anti-incretin" mechanism), activated by the same passage of nutrients through the upper intestine. The latter mechanism would act to decrease both the secretion and the action of insulin.

"In healthy patients, a correct balance between incretin and anti-incretin factors maintains normal excursions of sugar levels in the bloodstream," he explains. "In some individuals, the duodenum and jejunum may be producing too much of this anti-incretin, thereby reducing insulin secretion and blocking the action of insulin, ultimately resulting in Type 2 diabetes."

Indeed, in Type 2 diabetes, cells are resistant to the action of insulin ("insulin resistance"), while the pancreas is unable to produce enough insulin to overcome the resistance.

After gastrointestinal bypass procedures, the exclusion of the upper small intestine from the transit of nutrients may offset the abnormal production of anti-incretin, thereby resulting in remission of diabetes.

In order to better understand these mechanisms, and help make the potential benefits of diabetes surgery more widely available, Dr. Rubino calls for prioritizing research in diabetes surgery. "Further research on the exact molecular mechanisms of diabetes, surgical control of diabetes and the role played by the bowel in the disease may bring us closer to the cause of diabetes."

Today, most patients with diabetes are not offered a surgical option, and bariatric surgery is recommended only for those with severe obesity (a body mass index, or BMI, of greater than 35kg).

"It has become clear, however, that BMI cut-offs can no longer be used to determine who is an ideal candidate for surgical treatment of diabetes," says Dr. Rubino.

"There is, in fact, growing evidence that diabetes surgery can be effective even for patients who are only slightly obese or just overweight. Clinical trials in this field are therefore a priority as they allow us to compare diabetes surgery to other treatment options in the attempt to understand when the benefits of surgery outweigh its risks. Clinical guidelines for diabetes surgery will certainly be different from those for bariatric surgery, and should not be based only on BMI levels," he notes.

"The lesson we have learned with diabetes surgery is that diabetes is not always a chronic and relentless disease, where the only possible treatment goal is just the control of hyperglycemia and minimization of the risk of complications. Gastrointestinal surgery offers the possibility of complete disease remission. This is a major shift in the way we consider treatment goals for diabetes. It is unprecedented in the history of the disease," adds Dr. Rubino.

At a time when diabetes is growing epidemically worldwide, Dr. Rubino says that finding new treatment strategies is a race against time. "At this point, missing the opportunity that surgery offers is not an option."

Type 2 Diabetes May Be Caused by Intestinal Dysfunction

[Kim_in_TN]

I would be more interested in them determining WHY it plays a role in the development of diabetes rather than just having us all re-route our insides! I'm sure more than a few "knife-happy" surgeons would love this new theory!

I have always had problems with IBS and would love to know if something like THAT has influenced my developing D. Anyone else have these thoughts?

[REDLAN]

I would be more interested in them determining WHY it plays a role in the development of diabetes rather than just having us all re-route our insides! I'm sure more than a few "knife-happy" surgeons would love this new theory!

Unfortunately this article is more medical marketing than it is medical breakthrough.

Dr. Rubino has pioneered gastric bypass as a form of treatment for type 2 diabetes, which he performs at the aforementioned medical centre in the article.

And while he has managed to demonstrate that duodenal signalling may have a role for type 2 in rodents, in humans meanwhile...

there is no difference between the rates of remission for lap band or gastric bypass, which effectively disproves his theory.

rates of remission for type 2 are dependent largely on 2 factors.

1) amount of weight loss after surgery - regardless of surgery type.

and

2) how advanced the type 2 diabetes was before surgery. The more advanced the disease (higher FBG's or HBA1C) then the less likely it is that the surgery will cause remission of type 2.

anyone considering bariatric surgery, needs to weigh up the relatively high rates of complications, and high mortality rates and compare them to the risks of continuing with standard therapy for type 2.

more in depth discussion of this article here

Type 2 Cure?

[Tazmara]

All this reading has been very interesting, and has me pondering the course that my doctor is taking with me. She refered me to a surgeon, whom I saw yesterday. He is going to do a gastrointestinal scope and colonoscopy, but there is about a 6 month wait due to surgery waiting list. I had apologized to him for taking up his time, and that the symptoms I was experiencing were probably due to my diabetes, as per my family doctor. He did an examination and asked a lot of questions, then told me that it was not a waste of time. He suspects that my diabetes is caused by an intestinal abnormality. During his examination, he felt a lump, and is going to investigate that too. I am still trying to digest all this, and convince myself that the surgery is only to rule things out. Now I have added that what this article speaks of is what he may have in mind. I am a cancer survivor, and the thought that I may have cancer again terrifies me. But, the positive part of my brain is fighting with those fears and trying to tell me that everything will be okay. <soft smile> Thank you for posting this, so as to help reinforce the positive messages that this could be what he is going to offer as an option.

[Scrabblechick]

Thanks for posting this, BlueSky. I saw this article a couple of days ago and was mightily impressed. As soon as they start doing this surgery at the University of Alabama at Birmingham, and I'm sure UAB will do it, I'm DOWN THERE! First in line, and I'll fight with the insurance company about it, later!!

[Harold]

While I would agree that it does appear that some type 2s are caused by problems with the digestive system I would disagree with this surgery being the cure. These Diabetes Gastrointestinal Surgeries remind me of the practices of blood letting, to get rid of poisons, and cutting a hole through the skull, to let out the demons, that were performed for hundreds years.