Today, gastric bypass, along with other bariatric procedures, can only be prescribed for patients with a BMI of 35 and over.
Cornell Medical College. “Despite the strong association between the two, they don’t always go hand in hand. A significant number of people with lower BMI suffer from longstanding diabetes and its life-threatening risks and complications. Conversely, a person may be severely obese, with all the risks and quality-of-life issues that accompany that condition, but diabetes-free. For this reason alone, we need to start questioning whether BMI should be the only clinically appropriate way to decide who gets diabetes-targeted surgery.”
BMI became a parameter of eligibility for bariatric surgery about 20 years ago. A strict BMI cutoff makes sense when selecting candidates for bariatric surgery aimed at weight loss, but in Dr. Rubino’s view, it is an arbitrary and even discriminatory measure for separating those who qualify for life-saving intestinal bypass surgery from those who don’t.
“As an alternative,” Dr. Rubino explains, “patients should be triaged based on the severity of their disease, their metabolic profile, and other predictors of cardiovascular disease risk.”
Diabetes: A Surgical Cure?
A chronic disease that afflicts more than 200 million people worldwide, type 2 diabetes takes a huge toll on those with the disease. Over time, many patients are faced with potentially deadly complications affecting the kidneys, eyes, heart and extremities. For the most part, treatments such as diet, hypoglycemic medications, and insulin are ineffective in advanced disease.
Still, says Dr. Rubino, most of us don’t think of diabetes as a surgically treatable condition. Diet and exercise go far toward preventing the disease, which is why he agrees that preventive and primary care should receive priority in the realm of health care policy and planning. The problem is that lifestyle changes around diet and exercise have little or no impact on advanced disease, in which metabolic changes take on a life of their own and begin to ravage the body.
“Telling a patient with severe diabetes to eat a low-fat diet and go to the gym is comparable to telling a person with lung cancer to stop smoking,” Dr. Rubino says.
As one of the founders of the specialty known as gastrointestinal metabolic surgery, Dr. Rubino has tracked the benefits of bariatric procedures — especially those that reroute rather than simply restrict the digestive tract — when performed in severely obese patients with diabetes. He and his colleagues have found that immediately after intestinal bypass surgery, the disease improves radically, often to the point of complete remission. These results, he says, appear to be unrelated to weight loss.
Based on earlier studies and on clinical experience in other countries, Dr. Rubino and his colleagues have found that removing portions of the jejunum or duodenum — the upper part of the small intestine right below the stomach — leads to spontaneous improvement or even resolution of diabetes. The same holds true when the surgeon simply inserts a tube in that part of the intestine, allowing food to pass through without coming into contact with the area. These findings suggest that when food normally passes from the stomach into the upper end of the small bowel, it triggers a cascade of hormonal reactions that cause diabetes. Understanding precisely how and under what circumstances such reactions occur is Dr. Rubino’s longer-term research goal.
American Diabetes Association Consensus Statement
The idea that diabetes can be cured has been gaining support. In the November 2009 issue of Diabetes Care, the official publication of the American Diabetes Association, a group of 12 clinical experts, including Dr. Rubino, published a consensus statement that defines remission and cure, cautiously suggesting that the latter is synonymous with a remission of five years or more.
“The statement implicitly recognizes that remission is achievable only by surgery,” says Dr. Rubino. “It states that remission exists when normal glycemia is obtained in the absence of medical therapy; hence, by definition, medical treatment cannot achieve remission.”
Broadening Access to the Surgical Option
At NewYork-Presbyterian/Weill Cornell, Dr. Rubino performs the standard Roux-en-Y bypass procedure in patients with a BMI over 35, who form the greater part of his practice. Most of them come to him seeking treatment for both obesity and type 2 diabetes. Now, the potential benefits of intestinal bypass are being extended to 50 non-obese patients as part of the current study.
Dr. Rubino’s efforts have already begun to effect a shift in diabetes treatment guidelines at the highest level. In 2007, he was the lead organizer of the first Diabetes Surgery Summit, held in Rome. The conference issued a set of recommendations, now approved, regarding the use of surgery in severe diabetes. As a result, Dr. Rubino says, the American Diabetes Association has now recognized diabetes surgery as a viable option for people with BMI of 35-plus in a 2009 supplement to its Standards of Medical Care in Diabetes document.
Qualifying individuals interested in enrolling in the current study may contact Mayra Morales at (212) 746-5925 or mlm2010@med.cornell.edu, or visit https://www.cornellsurgery.org/patients/services/gi-metabolic/index.html.