The Evolving Field of Metabolic Surgery
Weight expert Dr. David Cummings discusses why bariatric surgery goes far beyond weight loss for type 2 diabetes.
By Jessica Dong and Kelly Close, diaTribe
Dr. David Cummings, a highly respected researcher from the University of Washington, Seattle, talked to us about the evolving field of metabolic surgery for type 2 diabetes. Dr. Cummings is the Deputy Director of the UW Diabetes Endocrinology Research Center. He has spent the past 20 years specializing in gastrointestinal surgery, studying its effects on diabetes remission (please see the Metabolic Surgery Primer at the end of the article for specific definitions), and the mechanisms for how body weight, glucose, and appetite are controlled. In 2004, President George W. Bush presented him with the US Presidential Early Career Award for Scientists and Engineers – the highest award given to young researchers by the US government. We've been lucky to follow his work at multiple scientific meetings over the last several years. Dr. Cummings spoke with us on a range of topics in our interview including (i) rates of diabetes remission and relapse after gastric bypass surgery; (ii) what criteria will make someone have a more successful operations; (iii) what the risks are; (iv) safety of the various types of metabolic surgeries; and (v) what misperceptions exist about the surgery.
Kelly Close: Let's start with the basics – your work and what you call it. What is the rationale behind the shift towards using the term "metabolic surgery" instead of "bariatric surgery"?
Dr. Cummings: I think there has been a shift in mindset about the reasons for seeking out surgery. We are now considering surgery an intervention to treat diabetes. Baros is a Latin term for weight, so bariatric surgery is weight-loss surgery. I am very much in favor of trying to re-brand this as metabolic surgery for some patients. It started in 2007 at the Diabetes Surgery Summit (DSS) that I helped organize in Rome, where experts in the field gathered to discuss the use and study of gastrointestinal surgery to treat diabetes as a main outcome rather than having weight-loss surgery with diabetes improvement as a secondary consequence.
Diabetes Remission After Gastric Bypass
Kelly: Some researchers call gastric bypass surgery the most reliable cure for type 2 diabetes. Could you talk about the rates of success?
Dr. Cummings: If you have type 2 diabetes and have gastric bypass, you enjoy complete remission in about 80% of cases. Remission means that, for at least a period of time, you'll come off all your diabetes medications, including insulin, if you used to be on it, and have non-diabetic glucose levels (an A1C below 6.5%). I'm not promising that all 80% of people who remit will be completely normal, so a certain percentage of those will have A1Cs between 6.0% and 6.5%. But it's very well established that about 80% of patients will undergo remission as defined above.
Now, the question of how long diabetes stays in remission remains controversial. This is because of a paper that Dr. David Arterburn et al. published very recently in Obesity Surgery, where he found that about a third of patients who experience remission end up relapsing.
Jessica: Over what time period was that?
Dr. Cummings: Well that's the key thing. The median length of relapse was eight and half years. Eight and a half years of not having diabetes at all. The press got a hold of the paper, and they spun it as saying lots of people with diabetes who have remission get diabetes again, implying that if your diabetes is only going to be temporarily remitted, you shouldn't have surgery. It wasn't worth it.
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James Joyce said that “mistakes are the portals of discovery.” I wonder if insulin levels have been our mistake. Could it be that this hellish week of blood sugars were somehow meant to be? Drastic times call for drastic measures, right? Maybe we were too afraid in the past to take the plunge into drastic measures. Maybe this is oddly what we needed. We had to be truly frightened in order to make bigger, bolder changes. ...