Metabolic surgery may be a more effective nutritional intervention
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Research
Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment—Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial
Metabolic surgery may be a more effective nutritional intervention
In their paper “Nutritional intervention in patients with type 2
diabetes.. (the
LOADD study)” [1], Coppell et al do not appear to have considered the
role of
a far more effective form of nutritional intervention – metabolic surgery.
The relationship between obesity and type 2 diabetes is well
established and
metabolic surgery is recognised as an effective treatment option [2].
Indeed,
the startling effectiveness of operations such as gastric bypass and
duodenal
switch in inducing rapid and durable remission of type 2 diabetes [2]
often
within days or weeks of surgery has driven research that may lead to the
development of novel pharmacological agents [3]. Significant remission
rates
for type 2 diabetes are also seen following lower risk procedures such as
laparoscopic gastric banding (which has an operative mortality three times
less than that of laparoscopic cholecystectomy).
Dixon et al [4] demonstrated that in type 2 diabetics randomised to
either
laparoscopic gastric banding or best non-surgical treatment, gastric
banding
led to significantly more weight loss (mean 20.7% decrease), reduction in
HbA1c (mean 1.81% decrease) and, most importantly, greater remission of
type 2 diabetes (73% of banded patients versus 13% in the best medical
treatment group). Although the duration of diabetes was notably shorter
in
Dixon’s study, patients were heavier (mean BMI 37 kgm-2 versus 35.1 kgm-2
) and the benefits of metabolic surgery were observed over a significantly
longer follow up period than Coppell reported (2 years versus 6 months) .
The overall clinical benefits of nutritional intervention described
by Coppell et
al are at best very modest (with a mean reduction in HbA1c and weight of
0.5%, and 2kg respectively) and are of unproven value beyond 6 months.
Many patients with type 2 diabetes and obesity have a long history of
cyclical
weight-loss, followed inexorably by weight-regain; even Orlistat in this
patient group produces just 2% additional weight loss over placebo [5].
We would suggest that many patients with morbid obesity and type 2
diabetes might be better served by referral for metabolic (bariatric)
surgery.
In specialist units this is a safe, cost-effective [6] and durable
intervention
with significant remission of obesity related comorbidities in addition to
type-
2 diabetes [7].
The American Diabetic Association has recently recognised metabolic
surgery
as a treatment option for patients with type 2 diabetes [8]. Although
confirmation of Dixon’s findings in an RCT with a larger cohort is
urgently
required to allay concerns regarding the safety and acceptability of
surgery in
diabetics with a BMI <35 kgm-2, rationing this highly effective
intervention
on the basis of current arbitrary BMI thresholds may place inappropriate
barriers to poorly controlled diabetics accessing an effective treatment
for
their condition [9] .
Whilst it is undoubtedly true that the kind of nutritional
intervention espoused
by the LOADD study is a significantly cheaper option for healthcare
commissioners than metabolic surgery, to our mind the adage that “you get
what you pay for” still seems to hold true.
Conor Magee MD FRCS, Bariatric Fellow
Niru Goenka MD FRCP, Consultant Physician, Diabetes and
Endocrinology
David Kerrigan MD (Hons.) FRCSEd, FRCS, Consultant Bariatric Surgeon
Conflict of Interest:
None
References
1. Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM, Mann
JI.
Nutritional intervention in patients with type 2 diabetes who are
hyperglycaemic despite optimised drug treatment--Lifestyle Over and Above
Drugs in Diabetes (LOADD) study: randomised controlled trial.
BMJ;341:c3337.
2. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et
al.
Weight and type 2 diabetes after bariatric surgery: systematic review and
meta-analysis. Am J Med 2009;122(3):248-56 e5.
3. Rubino F, R'Bibo S L, del Genio F, Mazumdar M, McGraw TE.
Metabolic
surgery: the role of the gastrointestinal tract in diabetes mellitus. Nat
Rev
Endocrinol;6(2):102-9.
4. Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner
S, et al.
Adjustable gastric banding and conventional therapy for type 2 diabetes: a
5. Hollander PA, Elbein SC, Hirsch IB, Kelley D, McGill J, Taylor T,
et al. Role of
orlistat in the treatment of obese patients with type 2 diabetes. A 1-year
randomized double-blind study. Diabetes Care 1998;21(8):1288-94.
6. NICE. Obesity: Guidance on the prevention, identification,
assessment and
management of overweight and obesity in adults and children, 2006.
7. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach
K, et al.
Bariatric surgery: a systematic review and meta-analysis. JAMA
2004;292(14):1724-37.
8. Executive summary: Standards of medical care in diabetes 2010.
Diabetes
Care 2010;33(S1):S4-10.
9. Dixon JB. Referral for a bariatric surgical consultation: it is
time to set a
standard of care. Obes Surg 2009;19(5):641-4.
Rapid Response:
Metabolic surgery may be a more effective nutritional intervention
In their paper “Nutritional intervention in patients with type 2
diabetes.. (the
LOADD study)” [1], Coppell et al do not appear to have considered the
role of
a far more effective form of nutritional intervention – metabolic surgery.
The relationship between obesity and type 2 diabetes is well
established and
metabolic surgery is recognised as an effective treatment option [2].
Indeed,
the startling effectiveness of operations such as gastric bypass and
duodenal
switch in inducing rapid and durable remission of type 2 diabetes [2]
often
within days or weeks of surgery has driven research that may lead to the
development of novel pharmacological agents [3]. Significant remission
rates
for type 2 diabetes are also seen following lower risk procedures such as
laparoscopic gastric banding (which has an operative mortality three times
less than that of laparoscopic cholecystectomy).
Dixon et al [4] demonstrated that in type 2 diabetics randomised to
either
laparoscopic gastric banding or best non-surgical treatment, gastric
banding
led to significantly more weight loss (mean 20.7% decrease), reduction in
HbA1c (mean 1.81% decrease) and, most importantly, greater remission of
type 2 diabetes (73% of banded patients versus 13% in the best medical
treatment group). Although the duration of diabetes was notably shorter
in
Dixon’s study, patients were heavier (mean BMI 37 kgm-2 versus 35.1 kgm-2
) and the benefits of metabolic surgery were observed over a significantly
longer follow up period than Coppell reported (2 years versus 6 months) .
The overall clinical benefits of nutritional intervention described
by Coppell et
al are at best very modest (with a mean reduction in HbA1c and weight of
0.5%, and 2kg respectively) and are of unproven value beyond 6 months.
Many patients with type 2 diabetes and obesity have a long history of
cyclical
weight-loss, followed inexorably by weight-regain; even Orlistat in this
patient group produces just 2% additional weight loss over placebo [5].
We would suggest that many patients with morbid obesity and type 2
diabetes might be better served by referral for metabolic (bariatric)
surgery.
In specialist units this is a safe, cost-effective [6] and durable
intervention
with significant remission of obesity related comorbidities in addition to
type-
2 diabetes [7].
The American Diabetic Association has recently recognised metabolic
surgery
as a treatment option for patients with type 2 diabetes [8]. Although
confirmation of Dixon’s findings in an RCT with a larger cohort is
urgently
required to allay concerns regarding the safety and acceptability of
surgery in
diabetics with a BMI <35 kgm-2, rationing this highly effective
intervention
on the basis of current arbitrary BMI thresholds may place inappropriate
barriers to poorly controlled diabetics accessing an effective treatment
for
their condition [9] .
Whilst it is undoubtedly true that the kind of nutritional
intervention espoused
by the LOADD study is a significantly cheaper option for healthcare
commissioners than metabolic surgery, to our mind the adage that “you get
what you pay for” still seems to hold true.
Conor Magee MD FRCS, Bariatric Fellow
Niru Goenka MD FRCP, Consultant Physician, Diabetes and
Endocrinology
David Kerrigan MD (Hons.) FRCSEd, FRCS, Consultant Bariatric Surgeon
Conflict of Interest:
None
References
1. Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM, Mann
JI.
Nutritional intervention in patients with type 2 diabetes who are
hyperglycaemic despite optimised drug treatment--Lifestyle Over and Above
Drugs in Diabetes (LOADD) study: randomised controlled trial.
BMJ;341:c3337.
2. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et
al.
Weight and type 2 diabetes after bariatric surgery: systematic review and
meta-analysis. Am J Med 2009;122(3):248-56 e5.
3. Rubino F, R'Bibo S L, del Genio F, Mazumdar M, McGraw TE.
Metabolic
surgery: the role of the gastrointestinal tract in diabetes mellitus. Nat
Rev
Endocrinol;6(2):102-9.
4. Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner
S, et al.
Adjustable gastric banding and conventional therapy for type 2 diabetes: a
randomized controlled trial. JAMA 2008;299(3):316-23.
5. Hollander PA, Elbein SC, Hirsch IB, Kelley D, McGill J, Taylor T,
et al. Role of
orlistat in the treatment of obese patients with type 2 diabetes. A 1-year
randomized double-blind study. Diabetes Care 1998;21(8):1288-94.
6. NICE. Obesity: Guidance on the prevention, identification,
assessment and
management of overweight and obesity in adults and children, 2006.
7. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach
K, et al.
Bariatric surgery: a systematic review and meta-analysis. JAMA
2004;292(14):1724-37.
8. Executive summary: Standards of medical care in diabetes 2010.
Diabetes
Care 2010;33(S1):S4-10.
9. Dixon JB. Referral for a bariatric surgical consultation: it is
time to set a
standard of care. Obes Surg 2009;19(5):641-4.
Competing interests:
None declared
Competing interests: No competing interests