FROM THE DECEMBER 2012 ISSUE
The Bypass Cure
Type 2 diabetes can be reversed in the operating room. The implications are staggering for halting one of America’s deadliest diseases.
By Bijal P. Trivedi|Thursday, October 25, 2012
The best way to combat type 2 diabetes, doctors traditionally say, is through diet and exercise-induced weight loss, which sometimes remedies insulin resistance. But many patients never manage to sustain the changes for long, and improvements can take months or years, if they come at all. When lifestyle changes fail, patients must control their blood glucose with regular insulin injections or oral medications. The medical costs for an individual with diabetes are typically 2.3 times higher than for someone without the disease. The day before her operation, Rubio told me she had tried dieting but could not shed weight, even though she understood the consequences. “I was afraid diabetes would affect my feet and cause gangrene,” she explained through a translator, her eyes welling with tears.
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In March of last year, the International Diabetes Federation endorsed bariatric surgery as a type 2 diabetes treatment for obese patients, citing studies indicating that it triggers remission in about 85 percent of patients. Bariatric surgery is the umbrella term for all weight-loss surgeries reserved for obese patients. Gastric bypass is a subset of these surgeries that first divides the stomach into a small and large pouch and then connects the small stomach pouch to the lower small intestine; Roux-en-Y is the most popular gastric bypass surgery in the group.
The federation’s endorsement was an extraordinary validation of decades of research and medical experience showing that surgery to reduce food intake can alter the biochemistry of the entire body. It also marked the beginning of a major new assault on diabetes.
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Perhaps the biggest surprise about the bypass cure is that it is still so poorly understood by medical science. Teixeira can see firsthand that simply by replumbing the gi tract, he can also reprogram the body’s hormones and reset its metabolism. Three days after surgery, one-third of his diabetic bypass patients leave the hospital needing no insulin, or on lower doses, before ever losing a pound. The fact that surgery could affect diabetes was first noted as early as 1955, when Murry Friedman, then a surgeon at the Brooklyn Veterans Hospital, observed that three of his patients given gastrectomies—removal of part or all of the stomach—to treat ulcers also recovered from diabetes. But his finding was published in an obscure surgical journal and essentially forgotten in the dusty medical library vaults.
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In complementary work done in 2011, cardiologist Robert Gerszten of Massachusetts General Hospital showed that high levels of BCCAs, along with two other amino acids (tyrosine and phenylalanine), can predict a patient’s chance of developing diabetes. “These BCCA levels drift up 12 years before you develop diabetes,” Gerszten says, “even though insulin and glucose levels remain the same.” But he, too, is unable to answer the question of which comes first, the chemical changes or the diabetes remission. “We don’t know whether you’re eating too many amino acids, you’re metabolizing amino acids poorly, and that’s giving you diabetes, or whether diabetes messes up amino metabolism in ways we just don’t know yet.” Even if high levels of these amino acids are not causing diabetes, evidence suggests they are useful biomarkers for predicting who is at risk, enabling such people to adjust their lifestyle before they get sick. One plausible lifestyle change might be switching to a diet low in protein—eating less meat, nuts, beans, and lentils, for example—the main sources of BCCAs.
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