Is diabetes really that bad?
I’m to chat a bit about the option of using bariatric surgery to treat Diabetes. Maybe this sounds familiar, because the concept was validated back in the 90’s. Or, maybe it’ll sound crazy – how would surgery help correct a problem with insulin (which is a hormone) and blood sugar? And anyway, isn’t that pretty extreme? Is Diabetes really “all that bad?”
I see two problems with the usual attitudes towards Diabetes. Diabetes has become so common in the U.S. that the sense of urgency has dropped away. Traditional treatment plans focus on keeping the blood sugar from getting “too far” out of control, doing little about the ongoing progressive damage caused by diabetes and the related diseases. I hope we can renew our sense of urgency about the diagnosis and treatment of diabetes, because we can do better. We can offer better treatments, like using bariatric surgery to treat diabetes. Stick with me, and I’ll explain.
The problems with traditional diabetes treatment
Why do we need to use bariatric surgery to treat diabetes? It seems to me that traditional diabetes care has become complacent. There’s been a focus on the blood sugar elevations as the main target for monitoring and treatment. The problem is that the blood sugar elevation is a surface manifestation of a deeper metabolic imbalance, which seems to be Insulin Resistance. Furthermore, traditional treatment has focused on diabetes as an isolated condition, but instead it’s part of a system of diseases that includes obesity, polycystic ovarian syndrome, high blood pressure, systemic inflammation, and harmful fat profiles in the blood.
Insulin Resistance: The heart of the beast
I think it makes sense to think of this set of problems like the mythical multi-headed hydra. In this case, Insulin Resistance is the heart of the beast, and the several surface manifestations or “heads,” such as Diabetes, sprout from this core problem.
This helps us understand that even if you get a leash on the blood sugar, the ongoing metabolic damage will continue to happen. It’ll happen because blood sugar control does not take care of the other conditions such as High Blood Pressure or Obesity, and the pancreas keeps working overtime to compensate for the Insulin Resistance, leading to eventual pancreas burnout. In fact, many of the traditional medicines used for diabetes lead to more weight gain, which of course leads to worsened Insulin Resistance, worsened Diabetes, more weight gain, and onward in a vicious worsening spiral.
I can complain about these problems with traditional diabetes care, without blaming patients who have diabetes, or their doctors. Traditional medicine has not had the tools to do much more than try to keep a lid on the blood sugar level. But there’s a better way, which is using bariatric surgery to treat diabetes, and that’s the subject of this blog. And we need to think hard about this “better way,” because Diabetes is not just a bad disease, but it affects a LOT of people. There’s a weird normalization of a scary condition when everyone knows someone who has it, but I believe complacency is the opposite of what we should be doing.
Type 2 Diabetes: “Insulin-Resistant Diabetes”
If you’re still with me, some clarifications are in order. This entire blog is about Type 2 Diabetes, which is sometimes called adult-onset diabetes. A better name for this condition is probably “Insulin-Resistant Diabetes,” because it looks more and more like Insulin Resistance is the key metabolic abnormality that underpins multiple diseases. As we’ll discuss, insulin-resistant diabetes is far-and-away the most common form of Diabetes in the United States. In fact, about 95% of people with Diabetes suffer from Insulin-Resistant Diabetes.
Insulin-Resistant Diabetes and the Obesity Disease
Another key connection is the close relationship of Insulin-Resistant Diabetes with the Obesity Disease. Of those who suffer from Insulin Resistant Diabetes, about 90% also suffer from the Obesity Disease.
We can see in this image that almost all the folks with Diabetes also suffer from the Obesity Disease, and to my eye this group of people takes up a surprisingly large part of the U.S. population. When you think about that, it helps explain why using bariatric surgery to treat diabetes makes sense.
We can look at total numbers, and we can also look at trends. Most people have a vague idea that obesity and diabetes have been increasing in the U.S., but check out these graphs of rapidly increasing Diabetes over the last 15 years or so…
Not only do we find Diabetes and the Obesity Disease overlapping on the Venn diagram, we also see there is striking geographic overlap. Blue zones have more Obesity alone, and Red zones have more Diabetes alone. Purple shows they are rising together:
Since Diabetes and the Obesity Disease reinforce each other as diseases, there’s an unfortunate-but-accurate new term that researchers use for this combination; it’s “Diabesity.”
We already looked at the concept of Insulin Resistance as a metabolic disease with multiple illnesses or manifestations. The other reason we care so much about Diabetes and Insulin Resistance is that it causes progressive daily damage throughout the body. It has an especially harmful impact on blood vessels and nerves, which of course are essential for the healthy function of every organ. We find evidence of blood vessel and nerve deterioration with retinal damage, kidney damage, and loss of sensation especially in the toes and the feet. People with Diabesity have a much higher rate of heart attack, stroke, or amputation. People with Diabesity are saddled with high maintenance lives that don’t last as long, and during which they are less able.
Imagine that every day one lives with Diabesity, all the blood vessels are gradually being clogged, starting at the fine fiber-like capillaries, and the vessels are also being hardened instead of keeping the normal elastic that helps blood flow smoothly. The nerve network looks similar, and it also suffers deterioration every day. This process slows down if the blood glucose is kept from going too high, but it does not stop.
Over a period of years, the progressive damage to the blood vessels and the nerves starts to cause damage in organs such as the retina or the kidneys, and it may lead to ulcers/infections in the feet or legs that require the damaged parts to be amputated.
So how do we best treat Insulin Resistance?
So, we can see it’s not enough just to get better control of blood sugar; we need to treat Insulin Resistance by getting the body to respond normally to Insulin – what to do?
Let’s go back to basics. The process of treating any disease usually begins with lifestyle modification, then medicines if needed, and then “interventions” if lifestyle and medications aren’t adequate.
The lifestyle interventions of low carb diet and exercise can improve blood sugar levels AND improve Insulin Resistance, so they are definitely worth doing. However, lifestyle treatment is not powerful enough once a person transitions from “prediabetes” to Diabetes, so medications are basically always required. Until recently, the meds available to treat Diabetes could make blood sugar better but usually made Insulin Resistance worse. This gave Diabetes patients an impression of successful disease treatment, while the pancreas continued to burn out and Insulin Resistance with Obesity continued to increase.
As long as Insulin Resistance continues, the pancreas has to pump out extra insulin, which worsens Insulin Resistance, requiring more insulin, in a vicious cycle until the pancreas “burns out.”
Pancreas failure leads to a need for higher and higher doses of meds, causing worse Insulin Resistance, worsening Obesity, back around to worse Diabetes….
GLP-1 and GIP medications (Ozempic, Mounjaro, etc.) are newly available options that may change the game. Not only do they promote insulin secretion from the pancreas, they also seem to enhance insulin effects, so that not as much is needed. In other words, these meds show potential to improve Insulin Resistance. They are well known to result in weight loss as well as improved blood glucose levels, suggesting they are actually getting to the root problem at the core of the Diabesity Combination. Sage Bariatric Institute’s medical team offer these and other medications to help people in this effort.
Even these modern meds are not powerful enough for many patients in the medium/advanced stages of the Diabesity disease, and this is where using bariatric surgery to treat diabetes comes in. The Gastric Sleeve has a 65% remission rate for Diabetes and the Gastric Bypass has a 75% remission rate, long term. Duodenal Switch has an even higher Diabetes remission rate in the range of 95%, but achieves that in part by creating malabsorption.
AND these operations treat the obesity disease through massive weight loss, AND they lead to improvement in numerous associated conditions, AND they lead to substantial sustained improvements in Insulin Resistance allowing patients to have normal blood glucose levels off medication, and to stop the ongoing damage. Just to be clear, the bariatric operations don’t work just by blocking food (though that is part of the story), they work on a hormonal level to get to the root cause of the Diabesity condition.
Diabesity CAN be treated!
I hope this blog helps you understand that, even though Diabesity is pretty common, it is NOT OK. Just getting control of your average blood sugar level is usually not enough. I believe that the right thing to do is to keep scaling up the intensity of treatment until you have the best possible control of the entire disease, including the Insulin Resistance at the root of the problem. If YOU suffer from Diabetes and Obesity, this condition we call Diabesity, you need to know that modern medical and surgical options can bring this disease into full remission in most cases. You deserve a long and healthy life; you should settle for nothing less.