October 2019 #obsm chat blog: The Twitter poll, public denial, and lives lost unnecessarily: Can a surgery “cure” Type 2 diabetes or put it into remission?
By Dr. Neil Floch, MD, Director of Bariatric Surgery, Nuvance Health System, CT., Associate Clinical Professor, University of Vermont Medical School
The medical establishment and the general public are not convinced that surgical intervention in addition to medical therapy is a better treatment for Type 2 (T2) diabetes than medical treatment alone. Despite the ample medical evidence supporting surgery published and shared through different media (including social media), Twitter polls over 3 years have shown no significant change in public opinion.
Bariatric surgery is the most effective long-term treatment for obesity. In addition to causing weight loss, bariatric surgery improves multiple medical problems. There is strong evidence of its positive impact on treating diabetes. In his 1984 paper, Walter Pories noted the improvement of T2 diabetes after performing the gastric bypass procedure. (1) A recent study by Ali Aminian MD published in JAMA, (Journal of The American Medical Association) demonstrated that patients with obesity and T2 diabetes who had bariatric surgery, (10% mortality), compared to controls (17.8% mortality), had increased survival at 8 years. (2)
The 5-year results of The STAMPEDE trial reported in the NEJM (New England Journal of Medicine) by Phillip Schauer MD compared medical treatment for T2 diabetes vs. medical treatment and bariatric surgery in patients with severe obesity. The results showed a 5% diabetes remission after medical treatment, 31% after combined treatment with gastric bypass, and 21% for combined treatment with gastric sleeve. Medications along with surgery were much more successful at controlling T2 diabetes than medication alone. (3) A similar trial by Mignone et al. revealed a 5-year remission rate of 37% for gastric bypass and a 63% for duodenal switch surgery. (4) When Chen et al. conducted a 10-year comparison of 78 patients with T2 diabetes who had gastric bypass with 80 patients with T2 diabetes treated medically, the results were striking. The surgical group had a 56% complete diabetes remission rate compared to the medical group, which had no remissions. (5)
The STAMPEDE trial created a pathway for further studies and the eventual recommendations by the ADA (American Diabetes Association) that would follow. A consensus statement was created, recommending metabolic or bariatric surgery for patients with obesity and poorly controlled T2 diabetes. Despite the publication of these recommendations by Francesco Rubino in Diabetes Care in 2016, mainstream clinical implementation has yet to be seen. (6)
A significant amount of denial for both obesity as a disease and the benefits of surgery persist in the public. According to the NORC/ASMBS poll from 2016, those patients who were eligible to have surgery but did not undergo the procedure noted the following reasons for not having surgery. (7)
•29% Cannot afford surgery
•11% Insurance would not cover
•16% Deny that they have obesity
•10% Scared of surgery
•6% Afraid of side effects
•The remaining: wanted to lose weight on their own, did not want surgery, saw no need for surgery, were not ready, did not talk to the doctor, the doctor did not recommend it (7)
A simple Twitter poll conducted in 2016 and again in 2019 similarly demonstrate that a high number of people don’t believe bariatric surgery could place diabetes in remission. Nor do they show any movement in public opinion during that 3-year period. Both times the poll asked the question: “Do you believe surgery can cure diabetes?” The question does not specify which type of diabetes can be cured as Type 1 cannot be resolved and T2 can go into remission. Respondents debated whether remission and cure are the same. But in the medical oncologic literature, disease-free beyond 5 years has been considered a cure, although remission is most acceptable currently. (figure 1,2.)
Lastly, the question leaves room for opinion, asking, “do you believe...” The vagueness of the question allows poll respondents to answer according to their own personal beliefs. Although the answer to the question, based on scientific evidence, should be yes, 51% of respondents said no in 2016 and 50% said no in 2019. The question remains, will the public accept the evidence in the medical literature? Or will individuals continue to underutilize bariatric/metabolic surgery as a treatment for T2 diabetes?
In our next @obsmchat Twitter chat, we will discuss treating T2 diabetes with surgery, including the evidence and reasons why physicians and the public remain reluctant to use bariatric surgery as a diabetes treatment.
1. What is your experience as a patient, provider or knowing someone with T2 diabetes in terms of treatment and complications of the disease?
2. What is the evidence supporting bariatric surgery for treating T2 diabetes?
3. Do medical professionals and patients believe this evidence? Why or why not?
4. Does the medical information on social media (including Twitter) influence your thinking about T2 diabetes and other diseases? What do you consider to be credible sources of information for making medical decisions?
5. What can medical providers do to better inform patients of the benefits of bariatric surgery for T2 diabetes?
(1) Flickinger EG, Pories WJ, Meelheim HD, et al., The Greenville gastric bypass. Progress report at 3 years. Ann Surg. 1984 May;199(5):555-62.
(2) Aminian A, Zajichek A, Arterburn DE, et al., Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity. JAMA. 2019 Sep 2.
(3) Schauer PR, Bhatt DL, Kirwan JP, et al. Bar-iatric surgery versus intensive medical therapy for diabetes: 5-year outcomes. N Engl J Med 2017;376:641–51.
(4) Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre randomized controlled trial. Lancet 2015;386:964–73.
(5) Chen Y, Corsino L, Shantavasinkul PC, et al., Gastric Bypass Surgery Leads to Long-term Remission or Improvement of Type 2 Diabetes and Significant Decrease of Microvascular and Macrovascular Complications. Ann Surg. 2016 Jun;263(6):1138-42.
(6) Rubino F, Nathan DM, Eckel RH, et al., Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care. 2016 Jun;39(6):861-77.
(7) Rosenthal RJ, Morton J, Brethauer S, et al., Obesity in America.Surg Obes Relat Dis. 2017 Oct;13(10):1643-1650. Figure 1. Figure 2. Figure 3.