Alas! Ileal interposition surgery for diabetes prevention?

See " Ileal interposition surgery improves glucose and lipid metabolism and delays diabetes onset in the UCD-T2DM rat, " by Cummings BP, Strader AD, Stanhope KL, et al, on page 2437. T he prevalence of diabetes has increased worldwide mainly as a result of the obesity epidemic. 1 In 2007, 23.6 million people in the United States were affected by diabetes, with type 2 diabetes comprising the majority of cases. 2 Another 57 million people had prediabetes, characterized by impaired fasting glucose and glucose intolerance. 2 Worldwide estimates of diabetes are as high as 171 million. 3 The current treatment of type 2 diabetes is aimed at increasing insulin secretion, decreasing glucose absorption from the small intestine or improving insulin sensitivity. Tight glycemic control can reduce some of the complications of diabetes; however, this goal is often unattainable partly because of poor patient compliance, inadequate health care delivery, and the high cost of therapy. 4 Several studies have shown that lifestyle intervention can slow the progression of prediabetes to diabetes , but whether this strategy can be implemented under everyday living conditions is uncertain. 5,6 Given the burgeoning twin epidemics of obesity and diabetes, recent attention has been focused on gastrointestinal surgery as an alternative to behavioral and pharmaco-logic strategies for managing diabetes. 7 Bariatric surgery is undoubtedly the most effective treatment for severe obesity. 7 In addition, studies have shown dramatic improvements in type 2 diabetes and dyslipidemia in severely obese patients after gastric banding , roux-en-Y gastric bypass and biliopancreatic diversion surgeries. 7 Procedures involving bypass of the upper intestine produce greater normalization of glucose that precedes weight loss. 7 It has been postulated that the entry of nutrients into the distal small intestine after roux-en-Y or other intestinal bypass procedures elicits a neuroendocrine response that reduces glucose and lipid levels, inhibits feeding, and reduces weight and fat. 7 This so-called " ileal break " mechanism is thought to be mediated , at least partly, by hormones secreted by L-cells, such as glucagon-like peptide (GLP)-1 and peptide YY (PYY). 7 In this issue of GASTROENTEROLOGY, Cummings et al 8 have performed a comprehensive analysis of ileal inter-position (IT) surgery in a rat model that closely mimics the " metabolic syndrome " in humans. 8 The University of California at Davis Type 2 Diabetes Mellitus (UCD-T2DM) rat was created by crossing obese insulin-resistant Sprague-Dawley rats with Zucker diabetic fatty …