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Health Sense

Weight-loss surgery increasingly seen as treatment for diabetes

Email|Print| Text size + By Judy Foreman
February 18, 2008

Elizabeth Soto used to say no when her husband suggested they go dancing. "I didn't want to go," she said. "I felt tired and ugly." She also was carrying 314 pounds on her 5-foot-7-inch frame and had diabetes.

She had gastric bypass surgery last June and now, at 235 pounds, the 38-year-old Chelsea resident said she feels "energetic and beautiful. I want to go out every weekend." Even more astonishing, her blood sugar, which goes awry in diabetes, normalized within days of her surgery. A delighted Soto now proclaims: "My diabetes is gone."

Doctors aren't quite ready to call weight loss surgery a "cure" for Type 2 diabetes, the most common form. "I would use the term 'remission,' because if people regain the weight, the diabetes will come back," said Dr. Martin Abrahamson, medical director of the Joslin Diabetes Center.

But doctors sure have begun encouraging their patients to get the surgery - for diabetes and a host of other problems. More and more doctors are recommending weight loss surgery to their obese and diabetic patients, and they are beginning to recommend it for less obese people, said Dr. George Blackburn, director of the Center for the Study of Nutrition Medicine at Beth Israel Deaconess Medical Center.

"We've all been blown away by the effectiveness of weight loss surgery," he said. "The most severe type of obesity, leading to all these horrible diseases - diabetes, heart attack, back pain, cancer - can be treated by this surgery."

Nationally, the number of weight loss operations soared 800 percent between 1998 and 2004, and another 11 percent between 2005 and 2006. Americans get more than 205,000 weight loss surgeries a year, according to the American Society for Metabolic and Bariatric Surgery - a number which is almost certain to keep climbing.

Research has shown that the surgery is getting far safer as it is performed more often. And more than 30 studies have found it effective for treating diabetes.

In the most recent example, a January study by Australian researchers, 60 obese, diabetic patients were randomly chosen to have laparoscopic adjustable gastric band surgery, a less drastic procedure than what Soto had, or regular treatment, which consisted of counseling on diet and exercise, plus medications, if necessary.

The results were stunning. Seventy-three percent of the surgical group were no longer diabetic at the end of the two-year study period, compared with 13 percent in the regular care group. The banding surgery, in which doctors place a balloon-like band around the stomach to make it smaller, had been assumed to be "the least effective operation for Type 2 diabetes, compared to the 'gold standard,' gastric bypass," said Dr. Erik Dutson, an assistant clinical professor of surgery at the UCLA School of Medicine. But it turned that banding, though it acts more slowly, also reverses diabetes.

Last summer, a Swedish study showed that obese patients who had any of several types of surgery were 29 percent less likely to be dead a decade later than patients who had tried to control their weight through diet, exercise, and other methods.

And Utah researchers found a 40 percent reduction in deaths from all causes for obese patients who had weight-loss surgery compared with those who didn't, as well as a 92 percent reduction in diabetes, 60 percent decline in cancer deaths and 56 percent drop in heart disease deaths for those who had had surgery.

To be sure, the surgery does not cure all problems. Many people still experience nausea, particularly if they eat sweets or greasy foods after the bypass surgery called Roux-en-Y.

Risk for suicide also appears to increase after weight-loss surgery, said Dr. Harvey Sugerman, editor in chief of the journal Surgery for Obesity and Related Diseases, perhaps because some patients "attributed all their depression to obesity. Then they have the operation, which takes care of the obesity, but they are still depressed.

"They thought the surgery would solve all their problems, but it didn't," he said.

Another factor in the rise of stomach surgery is doctors' growing skill. The national in-hospital death rate from weight loss surgery declined from nine deaths for every 1,000 surgeries to two between 1998 and 2004, and has declined even further since then, said Blackburn, who also chairs a panel of 100 experts studying weight loss surgery.

In Massachusetts, the death rate dropped from an already-low average of 3 per 1,000 surgeries between 1998 and 2003 to a three-year average (2004, 2005, 2006) of less than 1 death per 1,000 surgeries, Blackburn said.

And the biggest payoff of weight loss surgery may be yet to come - avoiding surgery altogether if scientists can understand a key question: Why does diabetes get better literally within hours after gastric bypass, even before patients lose weight?

"That's a very good question - every research center on the planet is working on it," said Dutson of UCLA.

"There's a Nobel Prize for anyone who can explain this," added Dr. Daniel Jones, director of the bariatric surgery program at Beth Israel Deaconess Medical Center.

Researchers already have some clues. In Roux-en-Y surgery, part of the stomach is tied off and the small pouch that is left is connected directly to the small intestine, a procedure that allows food to bypass the upper part of the small intestine. The big plus is that when you "change the plumbing," the production of insulin is increased, thereby reversing diabetes, Blackburn said.

Doctors suspect that bypass surgery somehow increases levels of a protein called GLP-1, which travels to the pancreas and tells beta-cells there to make insulin. (A new diabetes drug called Byetta seems to work in part through this mechanism.)

As the success of weight loss surgery grows, the number of patients clamoring for surgery is expected to soar further. Since 1991, federal guidelines have said that patients are eligible for weight loss surgery if their body mass index was 40 or more - someone who is 5-foot-6 and weighs 250 pounds, for example - or if it was 35 coupled with another serious condition such as diabetes, sleep apnea or heart disease.

But the recent Australian study pushed the envelope, offering surgery to less heavy patients. The US National Institutes of Health is already forming a committee to revisit its guidelines, Blackburn said.

For Linda Trainor, a nurse who works with weight loss surgery patients at Beth Israel Deaconess, watching obese and diabetic people get better is immensely gratifying. What she enjoys most, she said in an e-mail, "is their final freedom from self degradation."

Robert Sisson, a 49-year-old manufacturing engineer for Raytheon who lives in South Boston, can vouch for that. Until November, Sisson tipped the scales at 376. Then he had the banding procedure. Now, he weighs 306, and his blood sugar levels are much better.

Hopping off his exercise bike recently to talk, he said, "I should have had it done years ago. My wife is going to get it done this year."

"We've all been blown away by the effectiveness of weight loss surgery. The most severe type of obesity, leading to all these horrible diseases - diabetes, heart attack, back pain, cancer - can be treated by this surgery."

Dr. George Blackburn

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