Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
7 Mar

Diabetes is Now a Disorder of the Small Intestine?

plumberI’m not a doctor… and I don’t play one on TV, but fer cryin’ out loud, when will they learn? I just want to SCREAM sometimes. Seems bariatric surgery as a possible cure for type 2 diabetes was not enough. Old technology. Now the rocket scientists have determined that surgically bypassing the upper part of the small intestine can cure type 2 diabetes even better than that silly old gastric bypass weight-loss “breakthrough” of just a few months ago. Read this Science Daily article and tell me I didn’t eat bad mushrooms in my salad today.

‘When we bypass the duodenum and jejunum, we are bypassing what may be the source of the problem,’ says Dr. Rubino, who is heading up NewYork-Presbyterian/Weill Cornell’s Diabetes Surgery Center.

In fact, it has become increasingly evident that the gastrointestinal tract plays an important role in energy regulation, and that many gut hormones are involved in the regulation of sugar metabolism. ‘It should not surprise anyone that surgically altering the bowel’s anatomy affects the mechanisms that regulate blood sugar levels, eventually influencing diabetes,’ Dr. Rubino says.

Surgically altering the bowel’s anatomy? People, the source of the problem is bad diet and lack of exercise. Full stop. I’ve said it a hundred times here. Give me 95% of type 2s and I can cure them of diabetes forever in 90 days if they simply eat and exercise right. It’s not easy, but it’s free and doesn’t leave you messed up for life. Life is all about gene expression. Send the wrong signals and your genes express themselves in the direction of diabetes. Send the right signals and you’ll decrease insulin, increase muscle cell insulin sensitivity and normalize blood glucose, burn fat and preserve muscle. And all the recent discussion here on MDA about “all the many genetic differences we are seeing in the human population” doesn’t change a thing. The fact that some of us are predisposed to respond to dietary changes slightly faster or slower than others doesn’t remove the fact that our basic biochemistry all works the same. Yes, that same way we were designed by evolution. Yet, Dr. Rubino is suggesting that this miracle surgery might be the only hope for millions of us.

In fact, bypass of the upper small intestine does not improve the ability of the body to regulate blood sugar levels.

[but didn’t he just imply otherwise?]

‘When performed in subjects who are not diabetic, the bypass of the upper intestine may even impair the mechanisms that regulate blood levels of glucose,’ says Dr. Rubino. ‘In striking contrast, when nutrients’ passage is diverted from the upper intestine of diabetic patients, diabetes resolves.’

So what does that mean for a new surgically-corrected diabetic patient who finally decides to eat and exercise correctly? I guess he or she is just hosed for life? You gonna reconnect the bowel now? So much for homeostasis. And here’s the kicker:

There is, in fact, growing evidence that diabetes surgery can be effective even for patients who are only slightly obese or just overweight.

Leave it to a surgical specialist to come up with a plumbing cure for type 2 diabetes that applies to all 20 million in the US alone. Even at only $30,000 per procedure, let’s see, that’s six hundred billion dollars worth of business. Nice work if you can get it.

This, he explains, implies that the upper intestine of diabetic patients may be the site where an abnormal signal is produced, causing, or at least favoring, the development of the disease.

How exactly the upper intestine is dysfunctional remains to be seen. Dr. Rubino proposes an original explanation known in the scientific community as the ‘anti-incretin theory.’

By the way, I Googled “anti-incretin theory” and got four results, all as uttered by Rubino, so it’s unclear how the rest of the scientific community actually even feels about this theory.

I could dissect the rest of the article – everything said in it makes me want to puke. I know the good doctor is a well-respected specialist, but that just makes it even worse. I’m sure there’s a bunch of surgeons already drinking the Kool-aid and girding (maybe GERDing) their loins for a new rush in business. I can just feel my cortisol levels rising as I write this. Maybe the good doc can find a way to surgically bypass my adrenals. Just reroute the plumbing, doc. After all, stress is bad, and lord knows there’s no other possible way for me to avoid stress in my life. Am I just another hapless victim of bad genes?

Speak to me.

harrymoon Flickr Photo (CC)

Further Reading:

Lap Bands and Type 2 Diabetes

The Definitive Guide to Insulin, Blood Sugar and Type 2 Diabetes (and you’ll understand it)

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You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. The surgery/drug mentality in this country is ridiculous. It should be a “pre-requisite” for surgery that a person at least attempts lifestyle changes or becomes educated about the problem.

    Matt Metzgar wrote on March 7th, 2008
  2. Excellent rant Mark! I give it a 9.5 out of 10. Needed more 4-letter words, but all in all, very rational and well thought out. :-D

    To second what Mr. Metzgar said above, it’s all about “ease of use” in this country. Why should I exercise and eat right when I can have my (very intricately evolved) plumbing rerouted and blame my genes? It’s unfortunate that our fellow citizens have been educated that they are victims of their own bodies rather than masters of them.

    Cheers
    Scott Kustes
    Modern Forager

    Scott Kustes wrote on March 7th, 2008
  3. There’s one other quote from the article that made my jaw drop:

    “Type 2 diabetes, which accounts for 90 to 95 percent of all cases of diabetes…”

    That means 19 out of 20 people have a simple way to fix a problem that’s costing billions in health care per year? Ouch.

    I’d also like to mention that now when you google ‘anti-incretin theory,” the first thing that pops up is this post.

    McFly wrote on March 7th, 2008
  4. I work in the obesity research arena and there is another side to the story:

    1) People unable/unwilling to make the necessary commitment to lifestyle changes should not be left untreated. Yes, most everyone would agree that diet and exercise are the ideal way to combat type 2 diabetes. But that doesn’t mean you leave people to develop debilitating side-effects or to die if they don’t make perfect lifestyle choices.

    2) Researchers also seek to understand how the timing of food intake, energy substrate availability and energy expenditure affect the regulation of body weight and food intake. This website is dependent on research conducted in this area.

    Cherry-picking pieces of research which support a hypothesis and disregarding other pieces of research does nothing to elevate one’s argument.

    JDS wrote on March 7th, 2008
  5. OK, so, they want to take our omnivore’s intestine and shorten it to make it more like a carnivore’s intestine — and continue feeding the same diet? Madness!

    JDS – I am going to be brave and say flatly that I don’t agree with your first point. Doctors can and do fire patients for not complying with their advice. My doctor actually told me once that if I failed to follow a certain piece of medical advice, she would decline to treat me. So I simply do not buy that we should mutilate people who are unwilling to do what it takes to become healthy.

    As for unable, while there are certainly people who cannot exercise, the number of people who “cannot” make diet changes is virtually nil. Not everyone can afford to go for grass-fed beef and organic vegetables, but most of us can drop sugar and flour in favor of chicken thighs and eggs, even if it requires the sacrifice of something else like cable television. And for the people can’t afford even something as basic as healthful food, shame on us as a society. So what should we as a society spend tens of thousands of dollars on? Assuring that a family has access to high quality foods? Or putting members of that family under the knife?

    Now, having said all that, I think that bariatric surgery does have a place. But you really gotta make an earnest attempt at other things first. I am sure that prospective patients actually put more thought into this than the surgeons like this fellow who advocate surgery as a miracle cure!

    Migraineur wrote on March 7th, 2008
    • You don’t need to drop your cable TV (although it’s probably a good idea anyway) to eat primal. Not everything on my plate is organic. The MOST important thing is to drop all the processed food in favor of the less processed food. It’s not hard to buy pre prepared vegetables and greens and then combine them with pre prepared meat with a simple home made vinegar and olive oil dressing. Eating primal is as simple as you want to make it; so make it simple, and simply do it!

      Grok on!

      Kenny wrote on July 16th, 2012
  6. Make people pay out of their own pocket for non-immediate life threatening surgery and you may have more people motivated to find alternate means….oh like say eating right and exercise?

    Mike OD - IF Life wrote on March 7th, 2008
  7. Quote:
    “Cherry-picking pieces of research which support a hypothesis and disregarding other pieces of research does nothing to elevate one’s argument.”

    This is a fair comment. I’ve now collected many sites/blogs that occasionally cite reports and studies supporting the low-carb lifestyle. They seem very persuasive to me.

    For the sake of balance I’m interested in sites that will refer me to studies proving the dangers or harm of low-carb diets.

    However, the study has to be intellectually honest. Citing junk food studies that include huge amounts of sugar, simple carbs, deep-frying in vegetable oil, etc. then blaming the “artery clogging saturated fats” won’t do it. It has to be low-carb as lived by sensible people attempting to improve their health, i.e.: Unprocessed meats, butter, eggs, vegetables – in other words, high fat and protein, minimal processing or packaging, and low or no carbohydrates.

    JDS or other readers, please feel free to respond. I’m genuinely interested in getting both sides of the story.

    chainey wrote on March 7th, 2008
  8. Thanks for the comment, chainey. It is taken to heart as we want to bring a fair and balanced approach to all of our content.

    Aaron wrote on March 7th, 2008
  9. So true, been there, done that! Type 2 diabetes was a lifetime ago (maybe 2 yrs) before changing lifestyle (oh and breast cancer too!!)

    sarena wrote on March 7th, 2008
  10. Im sorry but I felt insulted when you said It can all be fixed by eating and exercising right. That’s not true at all, i know about 3 people with Type 2 that also eat and excerise right but still have plenty of issues because of Type 2…you’re ignorant..not everoyne is the same and for most ppl with T2 eating and excerising obviously doesnt work

    insulting wrote on March 7th, 2008
    • Type 2 typically can be treated w/proper eating (which doctors are NOT educated about and the diets they give patients will make it NOT get better) and exercise. I’m NOT ignorant on this issue as my husband is chronically ill with several things, including Type 2 Diabetes. Everything the docs asked, we did but he still got sicker and sicker every year. A few months with a WAPF member nutritionist saw him be able to drop one of two of his diabetes meds and reduce one of his heart meds. We are just now adding exercise to this routine. Stop listening to mainstream docs that will not help b/c they don’t know how to help. Be proactive and stop walking around, stomping your foot, declaring to the world like a two year old that you are offended.

      Reagen D. (@RedDesilets) wrote on July 13th, 2012
      • Just wanted to say “Thumbs Up” to your comment! Reagen D.

        Lucy wrote on July 13th, 2012
  11. Insulting,

    Sorry you feel that way. I don’t meant to insult type 2’s. I do mean to insult an industry that thrives on selliing type 2 meds for the rest of their lives (our rerouting their plumbing). I’m afraid a “can’t do” attitude is what helps keep many T2s from fully exploring their health options. I bet if you gave me details of what your friends tried, I could show you where they might have attempted some “natural” method that was doomed to fail. Take it from Serena who commented just before you, or from one of my employees who recently went from 225 and a full-blown type 2 to 163 and zero type 2 in 90 days. I see it happen all the time. I hope your friends can give it another try. I’m willing to help.

    Mark Sisson wrote on March 7th, 2008
  12. I don’t know about anti-incretins, but you got me reading about incretins. There’s one called “gastric inhibitory polypeptide” that apparently prods the pancreas to release insulin during periods of hyperglycemia. I guess it’s purpose is probably to signal to the pancreas that the increase in blood sugar is from dietary sugars, rather than just a glycogen dump from the liver. When mice are bred without receptors for the gip hormone, they are normoglycemic, and are insulin sensitive, but react poorly to a glucose tolerance test, the digestive system being unable to warn the pancreas of the coming flood of glucose. The mice are also resistant to obesity.
    Gastric inhibitory peptide is released in reaction to dietary fat, as well as sugar, which suggests a problem; fat and sugar together could lead to higher levels of insulin in reaction to a meal even though the fat itself does not directly cause the pancreas to secrete insulin. Fat alone wouldn’t cause the increase in insulin, since Gastric inhibitory peptide only causes increased insulin secretion when hyperglycemia is present.
    Naked mole rats are extremely long lived for rodents, and share certain things with those gip knockout mice-extreme glucose intolerance, excellent glucose control when eating their natural diets, and lowered insulin levels. (One study I was reading the other day described their levels of insulin as pretty much unreadable, it was that low!) Who knows, maybe this guy’s on to the fountain of youth, here.
    I don’t know about these anti-incretins, though; bypassing the upper small intestine would pretty much cut out the incretins themselves, which sort of makes anti-incretins sort of a moot point, doesn’t it?

    donnyrosart wrote on March 7th, 2008
  13. Donny – that’s fascinating. So one could hypothesize that the effect of this surgery would be a decrease in obesity but an increase in all of the other problems caused by unstable blood glucose – reactive hypoglycemia, mood and concentration problems caused by low blood sugar, glycated proteins (from high blood sugar levels), damage to small blood vessels and nerves, heart disease, kidney disease, and blindness. In other words, you’d be unhealthy, but you’d be thin.

    In my mind, there’s nothing scarier or more dangerous than taking a complex system and chopping part of it out with an ax.

    Migraineur wrote on March 7th, 2008
  14. Donny,

    Thanks for adding this information. It’s very interesting stuff. I agree with Migraineur that whether or not you can achieve a short-term fix by bypassing the secretion of one or more hormones or polypeptides you inevitably disrupt a sensitive system. As “Rube Goldberg” a device as the final human form is, it is a complex collection of feedback systems that ultimately fails if one or more of the loops is circumvented. May not be tomorrow or next week, but at some point the attempts at acheiving homeostasis are overwhelmed and the result is a breakdown. The operation was successful but the patient died…

    Mark Sisson wrote on March 7th, 2008
  15. Interesting argument. On the other hand, I do think it’s unfair to say it’s “all their fault” for people who are overweight and can’t get themselves exercising. It’s like the old school of morality, saying that a person must just have a weak character or something, and that’s why they can’t get exercising. How many times in a person’s daily life do they find themselves not doing things they should be doing, even simple things like letting the dishes pile up. Just looking at how challenging it is for many of us to maintain good habits in the basics of life, how can we just expect people who are already in the “bad end” of the scale with regard to obesity/overweight/inactivity to do a complete life change at will?

    I’m not saying that individual choice doesn’t play a part, but it’s something that we should be aware of that it’s more challenging than just saying people “should exercise and eat healthy.” I agree that surgery is not a great option, but it makes sense for it to be available for people who have failed to achieve their goals after diet, exercise, and actual counseling have all had a turn.

    Daniel wrote on March 8th, 2008
    • It’s not always weak character but MOST people do make bad decisions. And when they start trying to change, they can be overwhelmed if they don’t have a guide and give up. We have been there many times. Love love love my nutritionist and don’t know if we can get there. What is missing is people that are willing to get a second or third opinion from someone that is not a mainstream doc. Docs really ruined my husband but we are on our way to recovery, finally.

      Reagen D. (@RedDesilets) wrote on July 13th, 2012
      • Not to mention all the misinformation from the FDA.

        Kenny wrote on July 17th, 2012
  16. The advantage that surgeons have over much of medicine is that we can “comply” our patient, and not have to struggle with needing their cooperative compliance. It may not be permanent but often we get a result that will last a while. That said, I would not operate someone who could treat their disease as well or better with lifestyle changes. The problem for the general medical practitioner is, of course, people want easy, quick results and will not make those needed changes. What should we do? You know the real answers lie in societal changes, not just this “evil” group or that one.

    Dr. J wrote on March 8th, 2008
  17. DR. J,

    For sure it’s a societal change that needs to happen. We live in a world where nothing is our fault – always someone else, the economy, bad luck. I used to have a TV show alled “Responsible Health”. The premise was that your health was the single most important thing in your life, and that until you took full reponsibility – not blame, but responsibility – for your current condition, it was going to be extremely difficult to make any progress. If everyone were able to simply say “I take full responsibility for who I am and how I got here,” compliance would be a whole lot easier for you docs.

    Meanwhile, I don’t ever want to leave the impression I think docs or anyone in Big Pharma is “evil.” I believe they probably all want to feel as if they are benefitting mankind in some way. Misguided at times, maybe. A cog in a broken machine, maybe…but not evil.

    Mark Sisson wrote on March 8th, 2008
  18. People unable/unwilling to make the necessary commitment to lifestyle changes should not be left untreated. Yes, most everyone would agree that diet and exercise are the ideal way to combat type 2 diabetes. But that doesn’t mean you leave people to develop debilitating side-effects or to die if they don’t make perfect lifestyle choices.

    That is due in part to repeated and continuous warning to patients that A) it’s impossible to do a carbohydrate restricted diet for any longer period of time and B) it’s an unhealthy diet to follow. Both are UNTRUE, yet repeated like gospel….repeat something enough and it’s considered truth, no matter how inaccurate it is.

    Like Mark, I say, give me a type II and within 3-months I’ll have their blood sugar normalized, their A1c down, their triglycerides down, their HDL up with high odds their mediation is reduced or eliminated AND they’ll like how they eat too!

    Regina Wilshire wrote on March 9th, 2008
  19. “Just looking at how challenging it is for many of us to maintain good habits in the basics of life, how can we just expect people who are already in the “bad end” of the scale with regard to obesity/overweight/inactivity to do a complete life change at will?”

    How about if their life depends on it or if they want to avoid going blind or if they end up having a few fingers and toes sliced off – they’re pretty good reasons to do a complete life change at will!

    Hopefully, if they do make this life change they do it with low carb to see real results. It angers me that a lot of diabetics do try but following the wrong advice and so that gets them nowhere fast.

    Sue wrote on March 12th, 2008
  20. 90 days won’t do it for me, but I do find that when I hit a certain weight my numbers climb. My magic number seems to be under 220 pounds..221+ and higher, and my sugars are nuts.

    I eat clean (cut out preservatives/chemicals) and work out with a trainer 2-3x a week…exercising regularly more than 6 months, eating clean 4 months now…but my A1C is still high…My problem is as I’m losing fat, i’m gaining muscle. I can almost guarantee like clockwork, once I hit below 220, bam, my numbers drop.

    I have a lot to undo

    Deb wrote on March 22nd, 2008
  21. If you get cancer people have some compassion. If you get diabetes you have failed and are doing something wrong! You are treated that way by your entire environment that all have miracle cures…
    In spite of the Diabetes ass. and my Dr’s advice I used a high protein/low carb diet..it helps, it does not cure. And what about the Government that filled our food supply with chemicals and margarine/trans fats that probably some people are more sensitive to than others. What about the wheat and corn steeped in roundup/poison so that the field weeds are controlled? Or the cows,fish and chicken that are raised on antibiotics and hormones..The Dr’s aren’t overprescribing antibiotics the farm stores and providers of farm feeds are filling the food supply to the farms to poison you.. I have been eating organic, high protein and small quantities plus working out and walking a long time. I know it is much more complicated than you make it out to be.
    I say we all quit giving the diabetes research people money. I don’t see any real progress..I am giving money to the people who can’t afford to test. Years ago there was a company in Bellevue WA. who sold and distributed low cost test strips. When I could not find them my pharmacist told me that they had been purchased by a major pharm company and all the low cost strips had been destroyed… I think that diabetes is a money making business …The confusion over diet, medication and the lack of progress are just the camouflage…Fight to save yourself..and look to countries that have a single payer health care system to cure this…they have incentive. Good Health to you, Have compassion!

    Rebecca wrote on April 22nd, 2008
  22. You people are a bunch of morons and sound like tom cruise on depresion. Modern science has discovered things like antibiotics and tests and treatments for many bad genetic traits that many people have that can not be cured by change of lifestyle. I personally struggled with my weight for years and as I got older slowly lost the battle. Ten months ago I had bypass surgery and can tell you it was the single best thing that I’ve ever done for myself. Period. It drastically reduces your chances of dying from cancer and cured my t2. And whats more I didn’t have to become a slave to exercise and diet. Keep up your rediculous fight to live right and I’ll just go on living happily normal and not being a slave to T2

    scott baker wrote on October 23rd, 2008
  23. “Ten months ago I had bypass surgery and can tell you it was the single best thing that I’ve ever done for myself. Period. It drastically reduces your chances of dying from cancer and cured my t2. And whats more I didn’t have to become a slave to exercise and diet. Keep up your rediculous fight to live right and I’ll just go on living happily normal and not being a slave to T2″

    How does it reduce your chance of dying from cancer and how did it cure your t2? When you say that you didn’t have to become a slave to exercise and diet – do you mean that you saw it as an easier option or that you just thought it was your only option. You wrote earlier that you struggled with your weight for years and as you got older slowly lost the battle. I don’t think you can lose the battle with weight – you just stop fighting because you believe that you can’t win.

    Sue wrote on October 23rd, 2008
  24. Scott, I wish you the best of luck with the path you have chosen.

    Mark Sisson wrote on October 24th, 2008
    • I’m a type 2 diabetic. People’s liberal use of “cure” is misleading. Going low carb, even undergoing surgery, will not cure one of diabetes. It does allow a Type 2 diabetic to get his/her diabetes under control. Either that, or the person has been misdiagnosed (ie, never had diabetes to begin with). But remains a chronic condition that is not cured. If it is true that one is cured of type 2 diabetes, then that person can go back to eating more carbs and still see his/her post-meal blood sugar remain the same as that of a nondiabetic.

      Of course you can, by analogy, treat Type 2 diabetes as having an infection. Stay away from the source of infection and you won’t get sick.

      You can also treat Type 2 as an allergy to carbs. Do not eat carbs so as not to get an allergic reaction.

      However you treat it, though, the sad truth is that the person still has Type 2 diabetes and unless you reverse the insulin resistance completely, that person is not cured.

      JD wrote on January 23rd, 2010
      • JD, it’s a semantic issue. If one is obese at, say 350 pounds and loses 175 pounds, is one still “obese”? No. As long as that person keeps eating right and exercising, the weight stays off and the person is not obese. It would be ridiculous for that person to say “I’m obese…I just weigh 175 now…” Same goes for type 2. Once you get your numbers in line, you are no longer type 2. That doesn’t mean that you can’t reacquire diabetic numbers by eating crap again some day, but as long as your BG and insulin are low today, you are NOT diabetic.

        Mark Sisson wrote on January 23rd, 2010
        • As someone with Crohn’s Disease I have to disagree with that.
          Just because I’m in remission, medicated and have reduced my stress levels and eat low G.I., low fiber foods so that my trigger-happy immune system isn’t punching holes and fistulas in my intestines does not mean I don’t have Crohn’s Disease.
          Unless I am misunderstanding what is the definition of “(insulin-resistant) diabetes”

          mm wrote on July 15th, 2010
  25. I just stumbled upon this blog…holy crap!

    Surgically altering the guts to fix diabetes lol…who would’ve thought.
    Back in the 50’s and 60’s they used to take the colon out to ‘cure’ constipation.
    (Fiber Menace, K. Monastyrsky)

    Primal Palate wrote on May 22nd, 2011
  26. To mm:

    My husband has Crohn’s Disease. He also has 52 hernias. He gets flare-ups when he eats GRAINS. The biggest offender is WHEAT / Gluten.

    If you have an illiostomy then eating low fiber helps so you don’t get plugged up. If you still have your colon you’re in better luck. But there are 2 different type of fibers, 1 of which is the offender, and the other isn’t.
    Insoluble fiber is the offender, the white stuff on oranges, nuts, mushrooms and everything else that’s a plant and isn’t chewed well. The flesh of fruit would be soluble, the skin insoluble (for a rough explaination).
    You have Crohn’s because you ate a diet that was high in grains and legumes your whole life.
    The military is notorious for feeding soldiers high carb crap through field rations.
    I bet you were in your late 20’s, early 30’s when your problems started with diarrhea.

    I wish you the best in controlling flare-ups. Like I said, ditching grains will be the BEST thing you could ever do for your guts.

    Crohn’s is the end product of Celiacs Disease. Fiber Menace is a Book you should read.

    Primal Palate wrote on May 22nd, 2011

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