Killing two (or more) birds with one stone – improving co-morbidities

Weight loss positively impacts type 2 diabetes. The strong correlation between diabetes and obesity has given researchers hope that addressing one disease could positively impact the second. Past evidence has shown that increased glucose control can be achieved through weight loss. In 2002, the National Institutes of Health published results from the Diabetes Prevention Program (DPP) in the New England Journal of Medicine showing that a slight reduction in weight through increased exercise and improved eating habits can reduce the risk of developing type 2 diabetes by 58%. Over the last decade there have been numerous observational studies showing remission of type 2 diabetes following bariatric surgery.

73% remission rate of type 2 diabetes according to a study published in JMAM. The design took obese patients with type 2 diabetes and treated half with laparoscopic adjustable gastric banding and the other with conventional weight loss therapy. At the two-year follow-up, diabetes remission was found in 73% of the surgical group and 13% of the conventional-therapy group. Other studies have shown nearly immediate remission of diabetes post surgery, but researchers are still unsure of the mechanism causing this improvement.

The cause/effect relationship is not fully understood. The most intuitive theory points to the fact that immediately after a procedure, patients consume significantly smaller amounts of food. This can cause starvation-induced alleviation of diabetes because the pancreatic b-cells are not challenged. Even after the patient gradually escalates food intake, the volume restriction creates a state of negative energy balance that improves glucose tolerance. Eventually, after significant weight loss, insulin sensitivity improves, b-cell function is repaired, glucotoxicity decreases, and full remission of type 2 diabetes can occur.

Malabsorptive procedures show better results for type 2 diabetes remission. With remission rates of 84% and 80% for gastric bypass and biliopancreatic diversion, respectively, researchers have found a 92% reduction in diabetes-related mortality post gastric banding. In addition, there appears to be a direct relationship between the level of malabsorption and the alleviation of co-morbidities such as hypertension and hypertriglyceridemia (i.e., greater malabsorption, grater improvement in co-morbidities). Studies we’ve seen indicate the remission rate of the two conditions is approaching 100% post-biliopancreatic diversion.

Currently, 34% of the US adult population is obese (BMI>30). From our calculations, there are roughly 225 million adults (20 years old and above), which gives an approximate figure of 76 million obese people in this country.

The facts are as follows: 60% – 90% of type 2 diabetes cases are related to obesity or weight gain and statistics show that one in five obese persons will become a type 2 diabetic. US-approved procedures and devices have shown resolution rates of type 2 diabetes in a range of 56% for vertical banded gastroplasty to 84% for biliopancreatic diversion with duodenal switch. In addition, hypertension was resolved in a range of 66% up to 100%, depending on the device or procedure.

In North America, type 2 diabetes accounts for 90-95% of all diabetics. Individuals aged 40-59 have a one in 10 chance of having diabetes, while 20% of those over the age of 60 have been diagnosed with the disease. In 2007, we estimate that these numbers equate to 18-19 million individuals with type 2 diabetes, of which nearly half of the diagnosed are over the age of 60. Each year, over 1.5 million new cases of diabetes are diagnosed in the US, with the diabetic population trending toward 10% growth annually.

Additionally, US demographic trends show that the fastest-growing sub-segment in the US is the 65 and older population. This trend holds true not only in the US but by global measure as well. The elderly population faces a greater risk of developing type 2 diabetes because of the high incidence of weight gain accompanied by reduced mobility and activity.

Given current trends, we believe that the number of diagnosed diabetics in the US will increase by close to 11% going forward, with cases of type 1 and type 2 diabetes growing at a similar pace. In 2005, the NDIC estimated that the direct cost of diabetes to the healthcare system was approximately $92 billion. Based on the increase in general costs for healthcare, the growing percentage of individuals developing diabetes, and the consequent increase in co-morbidities, we anticipate that the cost to the healthcare system has likely extended past $100 billion.

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