Can Gastric Bypass Surgery Lead to Diabetes Remission in Non-Obese Patients?

Dr. Francesco Rubino, chief of gastrointestinal metabolic surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, is now enrolling overweight and mildly obese patients - those with a body mass index (BMI) of 28 to 35 - in a study of gastric bypass surgery aimed at reversing Type 2 diabetes. Because of their non-morbidly obese status, these patients do not qualify for the surgery under current guidelines.

Today, gastric bypass, along with other bariatric procedures, can only be prescribed for patients with a BMI of 35 and over.

"The relationship between obesity and Type 2 diabetes is complex and needs to be looked at closely," says Dr. Rubino, associate professor of surgery at Weill 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 can develop 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 many patients, unfortunately, treatments such as diet, hypoglycemic medications and insulin are ineffective, especially in the case of 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 become less effective as the disease progresses and metabolic changes take on a life of their own and begin to ravage the body.

"Telling a patient with severe obesity or diabetes to diet and exercise is comparable to telling a person with lung cancer to stop smoking," says Dr. Rubino. "We all agree smoking is an important risk factor for lung cancer, but no one would suggest stopping smoking can cure the disease. Obesity and diabetes are often approached as if they were lifestyle issues, rather than established diseases, and this has influenced how we conceptualize the risks and benefits of therapies for diabetic and obese patients."