Metabolic surgery


By John DiTraglia



In our last column we talked about several studies of medications for prevention of MACE (=major adverse cardiovascular events) in patients with type 2 diabetes that appeared in last week’s issue of The Journal of the American Medical Association (JAMA). This week’s JAMA has an article called “Association of metabolic surgery with MACE in patients with type 2 diabetes and obesity.” (1) It turns out that “metabolic surgery” works way better than any machinations of drugs, much less diet and exercise, for type 2 diabetes. Those standard strategies are pathetic. Type 2 diabetes and metabolic syndrome are hardly ever cured and just keep getting worse without surgery which does mostly cure it for at least 5 years and probably forever.(2)

Rather than going into the boring details of the conduction of this study and the outcomes of surgery vs whatever else we do to treat obesity and it’s complications, we can just dwell on the societal meanings that are probably more important at any rate.

The most interesting thing can be gleaned right from the title of this report from the Cleveland Clinic. They called it “metabolic surgery” instead of the usual words “obesity surgery” or “bariatric surgery.” So it makes it sound like fixing type 2 diabetes and the metabolic syndrome is the real reason we are doing this and not the cosmetic reasons that I think are much more important to patients who undergo these drastic operations.

One caveat that argues with the results reported here, which agree with all the other observational studies of this issue, is that it is also observational. That means that the best proof can only come from taking a group of patients and randomly make half get the surgery and half get the non-surgery and see what happens. There are all kinds of unknowns that make some people do things that might also effect the outcomes and cannot be adequately accounted for without up front randomization.

But even more important than that problem which probably can’t realistically be solved in humans at this point, is the issue that surgery naysayers will inevitably bring up – the issue of compliance. It goes like this, “Sure surgery works better but if people just did what we tell them to do, lose weight, eat right and exercise then you wouldn’t even need medications which you also won’t take like you’re supposed to anyway and then you also would not need surgery.”

If you want to know my answer to that smug point of view just read the last 10 year’s worth of my fat science column.

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By John DiTraglia

1. Aminian A et al. Association of metabolic surgery with major adverse cardiovascular outcomes in patients with type 2 diabetes and obesity. JAMA. 2019;322:1271-82.

2. Livingston EH. The role of bariatric surgery in managing the macrovascular complications of obesity-related type 2 diabetes. JAMA. 2019;322:1259-60.

1. Aminian A et al. Association of metabolic surgery with major adverse cardiovascular outcomes in patients with type 2 diabetes and obesity. JAMA. 2019;322:1271-82.

2. Livingston EH. The role of bariatric surgery in managing the macrovascular complications of obesity-related type 2 diabetes. JAMA. 2019;322:1259-60.