Surgical treatment of diabetes
Diabetes: there is a treatment, but no one knows how it works
Alexander Berezin, Naked Science
For links, see the original article.
Despite the fact that diabetes has been known to medicine for thousands of years, what exactly causes it remains a mystery. Let's try to figure out why it is so difficult to understand this disease and whether humanity has a chance to get rid of it.
We are already used to the almost omnipotence of modern medicine. Dangerous infectious diseases are pinned to the nail, although a few hundred years ago one epidemic could have claimed 70 million lives, like a couple of world wars. Even patients with HIV, thanks to effective treatment, in recent years have received the same life expectancy as their healthy peers – and this disease has been known for less than 40 years.
The most dangerous diseases now remain those that, most often, are not directly related to any infections – for example, most types of cancer. Another, not so dangerous, is diabetes. At the same time, the incidence of MI is growing even faster than for cancer.
In 2013, there were 382 million established diabetics in the world, and in 2016 there were 425 million (+10.8%, every 18th person on Earth). Only direct deaths from diabetes in the world are 1.5 million per year, and another 2.2 million die from indirect deaths. In the next ten years, according to a number of scientific groups, deaths from it will be one and a half times more. We are talking about a full-fledged epidemic, more than 90% of cases of which account for type 2 diabetes ("sugar", although this name is rather misleading).
The incidence of diabetes varies from country to country, while the leading countries in terms of overweight population do not always show the highest incidence of diabetes. The reasons for this are not yet known / ©Wikimedia Commons.
Diabetes is known exactly how it manifests itself. The body reacts incorrectly to the hormone insulin, the level of glucose in the blood increases sharply. Thirst, frequent urination, vision problems, high fatigue, men have problems with potency. We will omit the long list of possible and sometimes fatal complications, moving on to the main problem. No one knows exactly what causes "sugar" diabetes.
Need to eat less?
The scientific journal Diabetologia recently published another article by supporters of the first hypothesis about the causes of a growing worldwide epidemic with millions of victims. The idea of the first hypothesis is simple: the most important risk factor for type 2 diabetes is overweight. If the weight is to blame, then we must think – and it is worth fighting this disease through its reduction.
The authors of the new work took the results of a long-term study of 11 192 Australian women in 1996-2015 and traced how changes in the body mass index correlated with the likelihood of type 2 diabetes (and during the observations, 162 of these women, 1.5%, became ill with it). As expected, obese people (normally this means a body mass index above 30) have a higher probability of developing "sugar" diabetes.
The more years a person has lived with a body mass index above 30, the higher the risk of type 2 diabetes for him. But aren't we confusing cause with effect? / ©Wikimedia Commons.
What is more interesting: the later in a woman's life obesity appeared, the lower her probability of getting sick was. For each year of later onset of obesity, the probability of the disease fell by 13%, which is quite a lot.
Researchers deliberately do not formulate a vision of the causes of the disease. But they conclude that preventing obesity or fighting it after it has occurred can significantly reduce the risk of the disease.
Previously, supporters of the first hypothesis – that diabetes is associated with overweight / an incorrect lifestyle or heredity – spoke more openly. It is no longer customary to write like this in scientific journals. But on the websites of major Western clinics, you can still find statements like this: "Type 2 diabetes has several causes, genetic and lifestyle are the two most important."
Why they try so hard not to write in scientific journals is understandable. The fact is that genes change slowly, and diabetes spreads quickly. Lifestyle is an extensible concept, and nowadays, in relation to diabetes, it is often a politically correct form of designation for obesity and low physical activity. However, this explanation is also lame. In the USA, there are 93.3 million obese adults alone, and there are three times fewer diabetics. If it were a matter of years spent with obesity, the masses of such people would not approach retirement without such a disease, as we see in real life.
A screenshot from the Mayo Clinic website, which even today, at the end of 2019, tells tall tales that there is allegedly no cure for diabetes. As we will show below, in fact, it's not like that at all / ©mayoclinic.org .
At first glance, it is unclear: why do we even need to know the causes of this disease? The answer is simple. Medicine often believes that it understands the causes of a particular disease and, accordingly, treats it based on them.
For example, the cause of pneumonia has long been considered stale air, so back in the 1910s, medical doctors by inertia recommended cold baths to patients with it (bearing, as it is now clear, great risks for the patient). Once the bulk of doctors understood the real cause of the disease, it became possible to influence it.
Cut to hell without waiting for peritonitis?
It all started almost a hundred years ago, when practitioners began to notice that after a number of operations, the symptoms of diabetes in people went away without return. Such cases have become widespread since the 1980s. Then they began to treat extreme obesity with gastric bypass surgery. With such an operation, only a small part of the available food is left in the stomach, which quickly causes feelings of its overflow and stops overeating. Many obese patients had type 2 diabetes, and they had it after surgery – for good. However, it helped only in 83.7% of cases, in the rest – the disease remained.
Various variants of gastric bypass surgery in the vast majority of cases eliminate the symptoms of diabetes. Of course, it also has its disadvantages / ©Nature.
A little later, another way to combat extreme obesity began to gain momentum: "biliopancreatic bypass surgery with the duodenum turned off." Technically, this is simply the exclusion of a part of the duodenum from the actively working digestive tract. And with him it turned out that 98.9% of patients had already stopped suffering from type 2 diabetes.
At that time, the "fat-centric" hypothesis of the causes of diabetes prevailed in medicine. According to her, everything seemed to be clear: operations reduce the absorption of food, people lose weight – so diabetes goes away. Therefore, for a very long time, for decades in a row, no one paid much attention to the results of such operations.
There is nothing new in such a story. English admirals in the XVI-XVII centuries knew that fresh fruits in the sailor's diet prevent scurvy. Therapists in the United States in the 1950s noticed that taking aspirin regularly had a lower chance of thrombosis, as well as a heart attack. But while the mechanisms of the therapeutic effect have not been clarified, most scientists and doctors tend to attribute them to some as yet unaccounted for factors.
However, over time, scientists have nevertheless established: "The mechanism of diabetes disappearance after operations to bypass part of the gastrointestinal tract remains unclear, but it is definitely not associated with weight loss alone."
The main sign that it's not about weight has become time. Symptoms of diabetes passed through days, rarely weeks, but weight loss during this period often did not have time to occur at all. In addition, patients often continued to eat a lot after surgery, but they did not show symptoms of the disease anyway.
Finally, some doctors began to try (in fact, at their own and the patient's own risk) similar operations on people with a little overweight, or even without it at all (there are a lot of such diabetics). And their symptoms also passed – although there might not have been any weight loss at all. In experiments on diabetic rats, the same thing was observed. Over the next 15 years, quite a lot of such operations were performed on diabetics – and they had the same effect.
It would seem that this is the solution. Yes, surgery costs money, but in the world, more than a quarter of a trillion dollars a year are spent on caring for diabetics. To operate on all 422 million means, over time, to recapture the costs of their surgical treatment. But it was not there.
Firstly, the mortality rate from such operations is 0.28%. However, we must take into account that they are now carried out mainly on people with a large and very large weight. And this is a serious risk factor that greatly increases the risk of death after surgery. Again, only direct deaths from diabetes per year claim the lives of 0.9% of those suffering from it.
More importantly, you have to live with diabetes for decades (and every year there is a chance of dying from its consequences), and surgery is a one–time risk. Statistical studies have shown that over seven years of observation, operated diabetics show mortality by 92% lower than the control group who had the same severity of the disease and the same excess weight. It turns out that the operation on average is noticeably safer than its absence.
The color of the sea wave shows the percentage of diabetics who need insulin injections and have not undergone surgery. Blue indicates those who have undergone surgery. Even five years after it, almost none of them needs injections, having a normal blood sugar level // ©Nature.
There is, however, also the second. Some people after such an operation cannot eat too sweet or fatty foods: they are sick of it in the truest sense of the word. Someone has an increasing frequency of diarrhea. Someone shows a reduced level of vitamins in the blood, and he is prescribed multivitamins. The reasons for this are obvious: the gastrointestinal tract of a person has developed for a reason, there are no "extra" spare parts at all.
Chopping roots: while in the dark
The ideal way out of the situation would be some kind of non-surgical treatment method that does not force you to turn off part of the gastrointestinal tract. So that you don't periodically donate blood to control the vitamins in it and so that you don't get sick from sweets. But such a method cannot be developed without understanding what exactly happens with diabetes and what mechanism it has.
Based on the fact that diabetes – contrary to what was previously thought – is reversible, it is obvious that it is controlled by some constantly acting factor associated with the intestines and/or stomach (the greater effectiveness of operations with the duodenum shows that, most likely, the matter is in the intestine).
Today, there are three hypothetical mechanisms explaining the cure for diabetes. The first one is the most vague: the operation forces the intestines to change the production of hormones related to food. The second mechanism: after surgery, the level of some bile acids increases, affecting the reaction of cells to insulin and, in the case of intestinal wall cells, their absorption of glucose.
The third hypothetical mechanism is the influence of the microbiome, bacteria and archaea living in our intestines as beneficial inhabitants. As a group of Israeli researchers found out in 2014, sweeteners like aspartame cause serious changes in the species composition of the microbiome in the intestines of mice. Some bacteria and archaea are replaced by others that previously made up a smaller part of the intestinal microflora. At the same time, such mice develop impaired glucose tolerance, a process followed by type 2 diabetes in humans.
At the same time, the transplantation of fecal material from such mice to others showed that those also immediately developed a violation of glucose tolerance. Even when the mouse gut microbiota was isolated from the animal and grown separately from it, the introduction of such microflora into a healthy mouse still violated its glucose tolerance. A similar mechanism has been shown for humans.
Of course, this does not mean that aspartame is to blame for everything: diabetes appeared long before sweeteners. But it is obvious: something in what we eat is "out of sync with evolution." The inhabitants of our gastrointestinal tract from this begin to wage interspecific wars. And when such a war ends, we begin to have problems with blood sugar levels.
Probably, the ideal approach to non–surgical treatment of diabetes would be to study what exactly is wrong with our diet - and either exclude it from the diet, or some other ways to maintain a normal species balance of the intestinal microflora.
It remains only to wait until these discoveries are finally made.
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