Diabetes: Have We Got It All Wrong?: Hyperinsulinism as the culprit: surgery provides the evidence

Walter J. Pories; G. Lynis Dohm

doi:10.2337/dc12-0684

Bench to Clinic Symposia

Diabetes: Have We Got It All Wrong?

Hyperinsulinism as the culprit: surgery provides the evidence

Walter J. Pories, MD, FACS⇓ and
G. Lynis Dohm, PHD

Brody School of Medicine, East Carolina University, Greenville, North Carolina

Corresponding author: Walter J. Pories, pories{at}aol.com or poriesw{at}ecu.edu.

Diabetes Care 2012 Dec; 35(12): 2438-2442. https://doi.org/10.2337/dc12-0684

In this “clinical” contribution to the Bench to Clinic Symposia, we will show data to support the hypothesis that fasting hyperinsulinemia is the initial underlying cause of type 2 diabetes mellitus (T2DM) and that the remission of the disease following bariatric surgery may be due to the correction of hyperinsulinemia. The intent of this article is to elicit critical thinking about the pathophysiology of T2DM in view of the effects of surgery and to open debate. If our hypothesis is correct, then more research resources should be focused on the cause(s) of fasting hyperinsulinemia and the therapies that may correct it.

The questionable, traditional focus on hyperglycemia

The study of diabetes has always focused on glucose. Whether the diagnosis was made by the attraction of flies to urine as described in ancient India in 1552 BC (1), the sweet taste of the urine noted by Shushruta in 400 BC (2), or our current dependence on fasting blood glucose levels, HbA_1c, and glucose tolerance curves, the severity of the disease is still measured by the level of hyperglycemia.

Similarly, our therapeutic directions also aim, almost exclusively, to reverse the hyperglycemia. In 1921 when Banting and Best reported that a pancreatic extract reversed the soaring glucose levels following a pancreatectomy in a dog, the use of insulin spread rapidly to children and adults alike. By the time Sir Harold Percival Himsworth noted, in 1936, that there were at least two types of diabetes (3), the objectives of T2DM treatment were already set; goals that still continue today. Even though type 1 diabetes mellitus (T1DM) and T2DM are virtually two opposite diseases, i.e., a total lack of insulin production versus abnormally high levels, the therapeutic goals for both entities continue to be the same: lower glucose levels by 1) giving insulin, 2) increasing insulin production, and/or 3 …

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