The Practical Diabetic

ATTD 2021 was held 2-5 June, 2021 and, thanks to dedoc, I had the privilege to attend and live tweet the presentations. This post is not a distillation but a summary of one particular presentation by Dr. Walter Pories.

Dr. Pories pioneered gastric bypass surgery and was the first to document the surgery leading to the remission of Type 2 diabetes. He is a world leader on the interplay of the surgery and its effects on Type 2 Diabetes and he is of the firm opinion that, while the procedure does indeed put Type 2 diabetes in remission, it is not a result of the associated weight loss. Let me review what he presented.

Firstly, Dr. Pories talked about how he developed the modern gastric bypass procedure in North Carolina in the 1980s.

With the surgical procedure going well and developing a good reputation for reversing severe obesity, a Dr. Jose Caro requested one of his patients be considered for the surgery even though she had poorly controlled Type 2 diabetes despite using insulin to try and control it.

Dr Pories agreed to do the surgery but, the mystery was, a few days after surgery the patient had normal glucose levels and no longer needed insulin. The same thing happened with other Type 2 patients referred by Dr. Caro.

Neither Dr. Pories or Dr. Caro could explain it and blamed each other for poor diagnostics. For the fifth patient who underwent the procedure Dr. Pories showed how the blood glucose levels and insulin requirements progressed after surgery.

A patient whose blood glucose was 495 mg/dl (27.5 mmol/L) before surgery despite being given 90 units of insulin, within a week, the patient no longer required insulin with measured blood glucose within the standard range.

Over 9 years, Dr. Pories saw similar results with a remission rate of 83%.

It was consistently shown that Type 2 patients had a significant reduction in HbA1c and in the requirement for medication. The weight loss associated with the surgery could not explain it because weight loss simply did not happen that quickly. Moreover, other metabolic issues were shown to be reduced through the surgery.

To solve the mystery, Dr. Pories looked at other gastric surgeries and considered their remission rates. The conclusion was the more the gut was bypassed, the better the results. Dr. Pories formulated a hypothesis that the cause of Type 2 could be bad signalling from the gut with the surgery effectively turning the bad signal off.

Another piece in the puzzle came from studying the lactate levels of people with Type 2 diabetes which were shown to be higher. Dr. Pories characterised lactate as the black smoke seen coming from a poorly tuned engine. It meant the glucose was not being metabolised correctly under the action of insulin.

It was shown that, after surgery, the lactate issue went away suggesting whatever was fixing the Type 2 diabetes was also fixing the broken metabolism.

Looking at the glucose processing cycle (Cori cycle) more carefully it suggested that the gut signal hindered the glucose processing and instead of 36 ATP units (the energy “currency” of cells) being produced, only 4 were being produced and a lot of lactate.

Dr. Pories talked about evidence from Romania comparing cell response to blood taken before and after gastric surgery which confirms a difference in the blood and therefore potentially a difference in the chemical signals it contains. He then presented his conclusions.

Does obesity cause Type 2 diabetes? Whatever the cause of Type 2, obesity simply does not make sense because Type 2 goes into remission under gastric surgery before the fat is gone and it does not explain the different rates of remission for different kinds of surgery. While eating sugary foods only worsens the problem by thrashing the broken energy cycle, it is not the cause of the disease. In other words, characterising Type 2 diabetes as a “lifestyle disease” misses the mark. It is clear that there is something fundamentally broken in the body which is usually fixed when the gut is removed from the equation.

Rather than think of obesity and a person’s desire for high energy foods as the cause of their Type 2 diabetes, see it as a symptom of someone who has a broken energy production engine leading to excess production of body fat and a lack of energy for the cells causing the body to crave high energy foods to compensate which, unfortunately, only makes the problem worse.

People with Type 2 diabetes deserve our respect rather than our judgement and an understanding there is far more going on with them than a lack of exercise and poor food choices.