My suggestions during the panels [at WCITD] were that we not use inadequate data to justify [performing surgery] on more people. If we are going to do it in more people, it should be because we think that it does improve diabetes. Whether downstream it causes more mischief or not — with regard to vitamin deficiencies, potential bone loss, and perioperative complications — we just don’t know that yet.

But as I have said before, I do recommend to selected patients that they get [metabolic surgery], and that they get it in a timely fashion.

Endocrinology Advisor: In your experience as a clinician, you mentioned that some of your patients are hesitant to undergo surgery in general.

Dr Nathan: Lots of them! Sometimes I present it to them and they say “no, thank you.” And it is not a question of them not understanding the risks and the benefits. My patients tend to be well informed. I even have them, with the agreement of both parties, meet someone who has had the surgery with a great outcome, and they still do not want to have surgery. Surgery is the kind of thing we think about for relief of pain or an infected appendix… but we do not think about it to treat chronic conditions or diseases. If there were surgery to cure type 2 diabetes, I am not sure whether people would do it or not. That’s just the way people think, and I think the same way.

Endocrinology Advisor: Do you think even with more evidence from the proper trials that anxiety about surgery will still remain a major barrier to uptake in metabolic surgery?

Dr Nathan: Absolutely. The arguments have been made that you can put diabetes in remission [with surgery,] which I think is the case… meaning patients will have to take fewer medications. Most patients will say, “yeah, but I am ready to take medications for this. I already take medications for my cholesterol.”

[Surgery] has a very delayed effect. If you say, “what if we could decrease your need to take a statin with a simple procedure? It is relatively safe, but is still under general anesthesia, with some complications to it. Would you have the operation?” My guess is that 99 out of 100 people would not.

I think there is a mindset against surgery for treating chronic conditions. If you are getting a knee or hip replacement, [which have been comparators to bariatric surgery at WCITD 2019], most people are immobilized and in pain. We are talking about delayed gratification vs immediate gratification.

Endocrinology Advisor: Do you have any forward-looking thoughts for people in the field of endocrinology coming out of this meeting? Perhaps relating to the conversation about obesity stigma?

Dr Nathan: I think the case that has been made to destigmatize obesity, so that we can move forward without that hanging over us, is the same argument as applies to diabetes. The [American Diabetes Association] has already approached this issue about people being stigmatized.

Endocrinologists continue to need to examine their own prejudices against [metabolic] surgery — which has its risks, but also has its benefits, which we should not exaggerate. Certainly, in terms of diabetes it has a palpable, demonstrable benefit.

There are only 3 or so ways you can have a remission of diabetes: one of them is to lose weight with diet (like in the DiRECT study), which can happen with good behavioral programs; there is surgery, which has the best data because frankly it reduces weight and maintains it better than almost anything else we have; and the third is acute, intensive treatment with insulin, which has been demonstrated mostly in studies in China.

So, if we are talking about remission of diabetes, I think endocrinologists have to remember that surgery is one of the things that will do that, and that it also ameliorates lots of other costs of being obese (eg, sleep apnea, joint problems). It is not simple or uncomplicated, and we should not exaggerate its benefits, but there are benefits to consider.

Interview has been lightly edited by Endocrinology Advisor.

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