qq-12 - EDITORIAL Editorials represent the opinions of the...

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EDITORIAL Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. Gastrointestinal Surgery as a Treatment for Diabetes David E. Cummings, MD David R. Flum, MD, MPH A PPROXIMATELY ONE-THIRD OF ADULTS IN THE UNITED States are obese, 1 and largely because of this, at least as many have diabetes or prediabetes. 2 With these escalating twin epidemics, the health care community has been challenged to develop novel treat- ment strategies. In this issue of JAMA , Dixon and colleagues 3 report a 2-year study in which patients with recently diagnosed type 2 dia- betes and a body mass index (BMI) of 30 to 40 were ran- domly assigned to receive conventional medical/ behavioral therapy (medical therapy and a focus on weight loss through lifestyle modification) or laparoscopic adjust- able gastric banding (LAGB) plus conventional medical/ behavioral therapy. The results were clear and striking. Com- plete remission of diabetes at 2 years was achieved in 73% of the patients in the LAGB group vs only 13% of those in the medical/behavioral therapy group, and the former ex- perienced larger reductions in blood glucose levels, gly- cated hemoglobin levels, estimated insulin resistance, use of diabetes medication, and several features of the meta- bolic syndrome. No serious surgical complications were re- ported, and minor surgical mishaps seemed no worse than the adverse reactions to diabetes-related pharmaco- therapy. As expected, the surgical group lost more weight than the medical/behavioral group (20.7% vs 1.7%), and the amount of weight lost was the dominant predictor of dia- betes remission. The percentage weight loss generally required for diabetes resolution was 10%, which was achieved in 86% of surgical patients but in only 1 patient in the medical group. Of the 34 patients who lost less than 10% of body weight, only 4 experienced diabetes remis- sion, and these individuals had particularly mild baseline disease. Conversely, of the 26 patients who lost more than 10% of body weight, diabetes remitted in all but 4. In short, diabetes remission after LAGB appeared attributable to weight loss, with no evidence of additional antidiabetes mechanisms; but by promoting greater weight loss, LAGB was far more effective than medical/behavioral therapy at improving diabetes. For a study in which surgery outperformed nonsurgical interventions, a natural question is whether the medical/ behavioral program was as good as it could be. Pharmaco- therapy was determined individually by an experienced dia- betologist, using all diabetes medications available at the time. In addition, lifestyle optimization was stressed, including reduced intake of fats, saturated fats, foods with high gly- cemic index, and overall calories, together with a physical activity program of more than 10 000 steps per day and 200 minutes per week of moderate-intensity exercise. Whether this program constitutes the optimal medical/behavioral in- tervention can be debated. However, participants visited a
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qq-12 - EDITORIAL Editorials represent the opinions of the...

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