The Father of Bariatric Surgery Discusses Diabetes


A Message from Dr. Edward E. Mason

The “Father of Bariatric Surgery,” Dr. Edward E. Mason founded The American Society for Bariatric Surgery in 1983 in Iowa City, Iowa. He was the first president of the ASBS and was instrumental in developing the International Bariatric Surgery Registry. He continues to dedicate his life to the field of metabolic and bariatric surgery. Though retired from the University of Iowa faculty, Dr. Mason continues actively to teach, speak and write.

Dear Friends and Readers:
There are two major types of diabetes: 1 and 2. Severe obesity causes the latter, and it is because overeating causes an increase in the length of jejunal villi, which increases the absorption surface by up to 250 percent. Thus, no glucose or other stimulant reaches the high concentration of L-cells located in the distal small bowel (ileum). When glucose fails to reach L-cells, there is no secretion of glucagon-like peptide-1 (GLP-1), which is the hormone required for prevention and resolution of type 2 diabetes mellitus (T2DM). I have been puzzled until recently as to why glucose does not reach the L-cells. Bypass of some jejunum allows glucose to reach and stimulate L-cell secretion of GLP-1.

The human race is threatened by obesity and T2DM. Surgeons are operating on less than one percent of individuals with obesity and T2DM who are candidates for surgical treatment. For treating T2DM in patients who have obesity from overeating, bypass surgery has shown that it should be possible to treat the T2DM pandemic with a hexose or other poorly absorbed, and affordable, stimulant of L-cell secretion. Tagatose is one such hexose that has been shown to be effective, but it has not been approved for lack of sufficient study. Surgeons are pleading for approval for more operations, but more time on the operating room schedule is what is needed for increasing the surgical treatment of obesity and T2DM with surgery. But, of course, surgery cannot provide enough time for epidemic. We need a poorly absorbed hexose or other secretory stimulant that would reach and stimulate secretion of GLP-1 by distal L-cells.

What caught my attention in overeaters was a rapid increase in length of jejunal villi. This increases the absorptive surface by as much as 250 percent. As a result, glucose is absorbed before it can stimulate L-cells located in high number in distal small bowel. Normal initial stomach emptying is with a gush, which overflows the duodenum and stimulates upper jejunum to flush in order to prevent hyperosmotic damage to intestinal lining. T2DM is GLP-1 dependent. It should not be treated with insulin. Because elevated plasma glucose stimulates secretion of insulin, the plasma insulin concentration in T2DM is higher than normal. T2DM is GLP-1 dependent and should be treated with GLP-1 rather than insulin, which is usually too high because of the effect of high glucose.

In 1988, Thompson et al[1] reported that intestinal glucose uptake in aged mice was increased. If this is true in humans, it would explain why some of us who do not have obesity do not have stimulation of L-cells as we age and develop T2DM. The Danish Flemming Dela found that the best results in resolution of diabetes by obesity surgery was in the patients who had normal functioning beta cells, and the earlier the operation the better the results. This does not, however, increase available time on the operating room schedule, which is what is needed to treat more than one percent of the candidates for such surgery. We need to find poorly absorbed stimulants of GLP-1 secretion to treat the epidemic of T2DM that is extending into our younger age population.

Ardestani et al[2] compared RYGB and adjustable gastric banding for effectiveness in eliminating insulin treatment after bariatric surgery. RYGB predicted insulin therapy cessation early and independent of weight loss. This, in my opinion, is consistent with the mechanism of exposure of L-cells to glucose and other secretory stimulants of GLP-1 secretion.

My wife of 71 years was a trained nutritionist. She died recently, supposedly with a biopsy proven adenocarcinomatous mass behind her pancreas, but neither primary nor metastatic cancer could be found at autopsy. Each evening Dordana and I ate a bowl of walnuts and four different dry cereals, each containing added vitamins. This was in order to provide our immune systems with whatever might be needed by cells that recognize and kill abnormal cells, such as cancer cells. Dordana died of natural causes, but without any cancer. There should be more study of dietary immunooncology and nutrition.

The human race is also threatened by carbon dioxide and other pollution of our atmosphere from living in the fossil fuel and iron-age. Carbon fiber genesis can replace iron and steel and decrease carbon dioxide from our atmosphere. Atmospheric carbon dioxide is twice the safe level. These are times of shifting paradigms that could save the human race. Carbon genesis is made of three one-molecular layers of carbon. It is being used in building cars and many other items as we move away from fossil fuels.

What happened to our international effort to decrease the number of aimed nuclear missiles? At one time, we were building special structures for retreat should there be use of such missiles, but now we ignore the threat or consider them a required deterrent to keep them from being used. There remain concerns about the human race. I love living. Too many surgeons and physicians I admired have found life too difficult and taken their lives. Let us continue survival in this miraculous and enjoyable world. Seek mechanisms over empiricism and life over certain irreversible choices. Beware of carbon monoxide. Don’t run the engine in a small closed garage for even a second. Love living in the safest air available. Dordana was taught as a child to read horoscopes. She never told anyone the bad news, but I could tell from the extreme organization of her things that she knew her time had come. She had been on nasal oxygen for 20 days with a 50-foot tube. I write this message on All Saints Day, and to me and many others whose lives she touched, Dordana remains a saint.

May you all continue to live the lives you love, which undoubtedly includes caring for patients with obesity and T2DM.

Edward E. Mason, MD

1.    Thompson JS, Crouse DA, Mann SL, Saxena SK, Sharp JG. Intestinal glucose uptake is increased in aged mice. Mech Ageing Dev. 1988;46:135–143.
2.    Ardestani A, Rhoads D, Tavakkoli A. Insulin cessation and diabetes remission after bariatric surgery in adults with insulin-treated type 2 diabetes. Diabetes Care. 2015;38(4):659–664.

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