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Richard Pratley Part 4, Bariatric Surgery and Treating Diabetes

In part 4 of this Exclusive Interview, Richard Pratley talks with Diabetes in Control Publisher Steve Freed during the AACE meeting in Austin, Texas about his message for health care experts and the use of bariatric surgery in people with type 1 diabetes.

Richard E. Pratley, MD serves as the Medical Director of the Florida Hospital Diabetes Institute. He is also a senior scientist at the Florida Hospital /Sanford-Burnham Translational Research Institute for Metabolism and Diabetes.

Transcript of this video segment:

Steve Freed: You’re presenting to a large group of endocrinologists.

Richard Pratley: You assume. Perhaps nobody will come. (laughter)

Steve Freed: I doubt that. But let’s change your audience to family practitioners, and pharmacists and nurses, people in the medical field that deal with patients with diabetes. Well, let me step back one second. The sign of a great speaker is if people take your idea and when they leave, they use your ideas. There are some speakers that will read slides and people walk out of there and they’ll forget half or most of what they were taught. But if you have an idea that is really great and they take that home and they put that into their practice. What would that be from your presentation?

Richard Pratley: I think that the main message I want people to take away with is that obesity underlies much of the metabolic as well as the cardiovascular complications of both type 1 and type 2 diabetes and that we can improve the treatment of these conditions markedly if we address its underlying abnormality. So weight loss with lifestyle, exercise is critically important for all of our patients with diabetes. And where needed, we should progress to using pharmacotherapy, if they can afford it, or recommend bariatric surgery. Bariatric surgery I think is still under used given the prevalence of obesity and diabetes that we have. New procedures are quite safe and well tolerated and have marked effects on improving diabetes control. One thing that we know from our many observations with long-term studies the sooner you get somebody under good diabetes control, the longer you keep them there, the better the outcomes will be, so we really need to aim for early remission of diabetes by treating it aggressively, not through a step-wise treat-to-failure approach. We also need to consider bariatric surgery quite early on so that we can get people into remission.

Steve Freed: There’s been a huge amount of researchers I am sure you are familiar with when it comes to bariatric surgery and sleeves and we have balloons. From your expertise, where do you think that’s going and what might be the most successful?

Richard Pratley: I am quite encouraged by the data with the Roux-en-Y gastric bypass surgeries as well as the newer gastric sleeve procedure, which also seems to be quite effective in reducing body weight and decreasing some of the metabolic complications. A little less enthusiastic about the gastric balloons. I view those as a more temporary fix. However, these surgical procedures have very good outcomes. I think the risk-to-benefit ratio justifies them in many people. Got to realize that if somebody has multiple comorbid conditions including diabetes, lung and cardiac problems, sleep apnea perhaps, they’re very high-risk so you need to balance their inherent risk against the risks of surgery and in many cases when you do that you’ll find out that the risk-benefit ratio favors surgery. One thing that we’re still trying to understand is how the benefits of bariatric surgery are really realized. Is it simply the weight loss and improvements in insulin sensitivity? The data don’t suggest that. Is it other alterations in hormones? We think that probably that’s the case. The importance of this is that could lead to new treatments in diabetes that don’t involve surgical interventions.

Steve Freed: When it comes to bariatric surgery, you know, we’re learning things all the time, especially about the hormones that are no longer there because of the bariatric surgery that could cause other issues. What have we learned about some of the hormones that are affected by bariatric surgery?

Richard Pratley: One of the first observations was that the hormone GLP-1, which is an incretin hormone produced by the gut, is 2-3–fold higher in patients who had the Roux-en-Y gastric bypass surgery and that level of increase is sustained for up to 20 years after the operation. Now we know that GLP-1 is beneficial for modulating weight as well as improving glucose control because we have drugs that work through this access, so I think that’s part of the explanation. We know less about some of the other gut hormones things like ghrelin. Ghrelin is an appetite hormone increases and causes you to be hungry and that is altered in patients who have Roux-en-Y gastric bypass surgery. Things like GIP, for example as well as potential hormones that we have yet discovered. Things in the foregut that are excluded from the Roux-en-Y gastric bypass surgery might be quite important for driving the metabolic complications associated with obesity and if we understood what those were, we might be able to target specifically.

Steve Freed: You talked about bariatric surgery. We don’t hear much about type 1s because we don’t see a lot of obesity with type 1s. What are some of the things that we’ve learned when it comes to type 1 and bariatric surgery?

Richard Pratley: As I mentioned we are seeing more and more of obesity and much more serious obesity in patients with type 1 diabetes. So, people are beginning to consider bariatric surgery as an option in patients with type 1 diabetes, but it’s a different animal. We don’t expect that diabetes is going to resolve with bariatric surgery in the same way that it can resolve with type 2 diabetes; however, there are other important medical benefits. There is one systematic review of all of the case series and case reports of bariatric surgery published by John Kirwan in Diabetes Care about a year ago. In that study, about 107 patients with type 1 diabetes underwent bariatric surgery. They found out the effects on A1c were variable, but there was a consistent weight loss. It was pretty similar experience in patients with type 2 diabetes and there was some other benefits as well such as lower insulin requirements. So, I think we need to systematically study the benefits of bariatric surgery in patients with type 1 diabetes because there’s also risks. One of the risks was apparent was the risk for ketoacidosis in the post-operative period.

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