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Interviewees: Pat Prescott, Wants diabetes surgery; Francesco Rubino, Weill-Cornell Medical College/NY Presbyterian Hospital
For Obese Only
When she’s dancing the samba, Pat Prescott is all smiles. But her frustration shows when she talks about her daily battle with type 2 diabetes.
A typical day for the academic research librarian is filled with one challenge after another revolving around her disease. Here’s her description of what she calls, “a good day for me.”
“I should have already, the day before, the night before, done grocery shopping. And obviously gone to the pharmacy whenever necessary. I should get up in the morning and cook vegetables and the proper protein and have the proper food available for that day, and plan out the whole day. When I leave the house in the morning, I’m gone for 14 to16 hours, so that means that all my medicines for the entire day have to be with me, and they have to be refrigerated or they have to be kept cold. That goes for things like needles and my glucometer and the test strips. And then I should be trying to figure out how to get at least 30 minutes of vigorous exercise in that day.”
“But that’s a good day,” she says. “That’s a day when I haven’t broken down and eaten like a one-by-one-inch sliver of cake at somebody’s birthday party, or I haven’t eaten a mango or some kind of fruit that really messes up my sugar. But if you can imagine doing that every single day and having that regimen every single day, it’s very tiring. You get used to it, but people around you don’t get used to it, and if you travel, or if you’re invited to someone’s house, it’s a major undertaking. Traveling is terrible. You just have to prepare for so many eventualities.”
“Is this working? No. Unfortunately, it isn’t working,” says Prescott.
So Prescott got excited after a friend had gastric bypass surgery for weight loss in 2004. “She was quite obese. And she told me, she called me afterward, and she said, ‘Pat, these people are coming out of surgery and they don’t have diabetes any more!’”
Prescott put her expert research skills to work reading the medical literature and found that evidence was indeed piling up that weight loss surgery has the side effect of improving patients’ diabetes. She began seeking out the surgery, but invariably, doctors told her she doesn’t weigh enough.
She was appalled when some even suggested that she could do something harmful to her health, gain weight, to qualify for the surgery. “That’s a terrible thing to do to deliberately put on weight in order to qualify for gastric bypass,” she says.
New Clinical Trial
But Prescott is now hopeful that a new clinical trial will change that. Led by surgeon Francesco Rubino of Weill-Cornell Medical College/New York Presbyterian Hospital, the new trial will test whether surgery similar to gastric bypass can improve diabetes in non-obese patients.
Rubino has spent the last decade researching how surgeries that bypass part of the small intestine improve the signs and symptoms of diabetes. He’s found evidence that those surgeries accidentally improved diabetes long before bariatric, or weight loss, surgery arrived on the scene.
“We have reports of remission maybe 80 years ago with surgeries that looked similar to bariatric surgeries in terms of techniques,” he says. “So remission of diabetes has been achieved unintentionally so far, it was achieved by other operations that were used treating peptic ulcers or gastric cancer, or more recently, obesity. But now we are shifting towards a new concept, which is using surgery to intentionally treat diabetes.”
As he wrote in the journal, Diabetes Care, obese patients who have a surgery called gastric bandingâ€”which only restricts the stomach, generally see their diabetes improve only after months of weight loss. But when patients have surgery that bypasses part of the small intestine, their diabetes symptoms often disappear within days.
“With some operations like gastric bypass, or similar procedures, the remission of diabetes is very quick after surgery, which even precedes the weight loss,” Rubino says. “And this occurs even without taking medications anymore, so this is what we call a remission. Maybe not a cure, but certainly a remission, and this is unprecedented in the history of diabetes. That is a striking observation that I think actually gives us a lot of responsibilities, because we need to find out why this is occurring. And at a time when diabetes is increasing in incidence, we must understand why this happens and how can we offer, not just surgery, but anything that we learn from this experience, to more patients than are actually offered hope today.”
In the paper, titled “Is Type 2 Diabetes an Operable Intestinal Disease?” Rubino described how tests with animals back up these observations. “Even those animals that have no obesity but they are still diabetic, they do have an improvement following surgeries that are very similar to gastric bypass,” he says. He also found that while the surgery improved diabetes symptoms in diabetic rats, it actually impaired glucose tolerance in normal rats.
And he discusses recent case reports of nonobese diabetic patients successfully treated with surgery in Europe. “Very recently we have seen diabetes surgery being applied to patients that are not obese with very satisfying rates of remission, Rubino says.
“Not a Cure”
“We can’t say that there is a cure for diabetes yet, because, technically speaking, to say that there is a cure, we should be able to know that we are actually dealing with the cause of diabetes,” says Rubino. “Unfortunately, the cause of diabetes is not known yet. So we can say that, in a clinical point of view, surgical remission of diabetes really looks like a cure, but we can’t speak about a cure yet.”
He hopes the clinical trial, as well as new laboratory research, will lead to an understanding of the cause. “It’s clear that we are facing one of the most fascinating opportunities we have ever had in the history of this disease, and I think it’s not an option to ignore that possibility,” he says.
A consensus conference of diabetes experts convened last year in Rome, Italy agreed. Known as the Rome Diabetes Surgery Summit, it developed international guidelines for conducting clinical trials on gastrointestinal surgery for treatment of diabetes.
Rubino hopes to begin recruiting for the US trial this fall.
Prescott says she is “holding her breath” hoping to enroll, and has been saving up her vacation and sick time so she’s ready if accepted into the trial.
“When I discovered that Dr. Rubino had come to this country and that he indeed was going to pursue this, I sat in my office and cried,” she says. “I just couldn’t believe it… I would be very discouraged right now, but I’m not, I’m hopeful. I think this surgery is going to become available some way, somehow for me.”
If it works, Prescott knows she won’t be the only one dancing.
“We want to be healed,” she says. “This is about getting well. This is about extending our lives.”
This research was published in Diabetes Care, February 2008. The paper was based on a presentation at the 1st World Congress of Controversies in Diabetes, Obesity and Hypertension (CODHy). The Congress and the publication were made possible by unrestricted educational grants from MSD, Roche, Sanofi-Aventis, Novo Nordisk, Medtronic, LifeScan, World Wide, Eli Lilly, Keryx, Abbott, Novartis, Pfizer, Generx Biotechnology, Schering, and Johnson & Johnson.
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