Meet Dr le Roux, Consultant in Metabolic Medicine at Imperial College London and Chair of Experimental Pathology at University College Dublin. During his career, he successfully established an independent research group and has been an important influencer in the field of metabolic medicine. His research focuses on diabetes and obesity, specifically the increased morbidity and mortality associated with these conditions.

Dr le Roux will be speaking at Obesity Update 2018, in the debate ‘Will metabolic surgery replace pharmacotherapy for the treatment of type 2 diabetes?’ Ahead of the event, we interviewed him to find out more about his career path, research interests and his position in the upcoming debate.  

 Q: Tell us more about your background and career highlights so far?

I am a metabolic medicine physician with an interest in obesity; specifically in how bariatric surgery and pharmacotherapy can improve patient outcomes.  I graduated from the University of Pretoria and completed my specialist training in Metabolic Medicine at St Bartholomew’s Hospital and Imperial College. I was awarded a Wellcome Clinical Research Fellowship and completed my PhD at Imperial College. I then received an NIHR Clinician Scientist Award, which enabled me to set up the Imperial Weight Centre, and was then offered a Chair at the Diabetes Complications Research Centre at University College Dublin. The proudest moment of my career was receiving the President of Ireland Young Research Award at Áras an Uachtaráin.

Q: What are you currently working on?

My research investigates using a combined approach of bariatric surgery with pharmacotherapy to reverse the complications of diabetes. We are aiming to treat people with diabetic complications, e.g. diabetic kidney, renal, neural or cardiovascular disease, with both surgery and medication to put these symptoms into remission and stop the development of the disease.

Q: What most excites you about your work and the contribution you can make?

I am most excited about the opportunity to hear what obese patients report about their disease, and applying this knowledge together with basic and clinical science to pursue these symptoms and understand the mechanisms of obesity. I am also excited about the progress we have made in the field; for example, the discovery that obesity is a subcortical brain disease opens up new treatment options, while also reducing the discrimination that patients suffer.

Q: The theme of the 2018 Obesity Update debate is whether surgery is more effective than pharmacotherapy in the treatment of type 2 diabetes. Can you tell us why there is a difference of opinion on this?

Until recently, bariatric surgery – that is gastric by-pass or sleeve surgery – was not considered to be a viable treatment for patients with type 2 diabetes. However, a systematic review of 11 randomised controlled trials, published in 2013, showed that those who undergo surgery do better and outperform patients on pharmacotherapy for weight loss, glycaemic and blood pressure control. This, of course, has great implications for type 2 diabetes patients.

Given the aforementioned trials and their results the question becomes: should every type 2 diabetes patient be offered surgery as a treatment? However, the issue here is not really whether or not we should use surgery – but if and when bariatric surgery is the best strategy to follow.

Q: You will argue that surgery cannot replace pharmacotherapy but, if surgery is so successful, why not?

The main issue is that not all patients with diabetes are the same – the risks of morbidity or diabetic complications are extremely varied and thus, their treatment options should accommodate these differences and find a balance between the risks and gains of bariatric surgery vs. pharmacotherapy.

Although the risks associated with surgery are very low, they still aren’t as low as those associated with medication. Considering this, patients at high risk of diabetic complications for whom best medical treatment is not sufficient may hugely benefit from surgery. On the other hand, for those patients who respond positively to pharmacotherapy there is little value in offering surgery as well.

Additionally, we must not forget that pharmacotherapy is constantly improving. Due to such advances, if we had a randomised controlled trial today that compared outcomes between surgery and medical care, it would be very difficult to imagine that surgery would have any additional benefits beyond best medical care when it comes to mortality. We’d love to say that if you have an operation you’re going to live longer but we simply don’t have that evidence. However, we do have evidence to say that using drugs, such as a sodium-glucose co-transport inhibitor or a GLP-1 analogue, will help diabetes patients to live longer.

Q: In your opinion, when would bariatric surgery be appropriate?

We should offer surgery when it adds value to the patients – helping them to lose weight, and achieve better glycaemic and blood pressure control – and to facilitate the work of diabetologists that treat these patients. It’s not about surgery against medicine, it’s about how surgery can make medicine better. This is precisely what’s done in cancer therapy – we use surgery to control the disease, then chemo or radiotherapy to keep it in remission. We don’t expect surgery to be sufficient on its own – after surgery we still follow the patient and make sure to control all the other consequences of the surgery.

In summary, the model should shift to actually using surgery as an add-on therapy to pharmacotherapy. This way, the benefit of using surgery is that patients need much lower doses of medication. It may allow someone who needs insulin to control type 2 diabetes to move on to requiring only metformin or other oral medications. That would be a massive improvement for the patient’s quality of life. Taking it a step further, a patient with fully controlled diabetes on oral medication could use surgery to put diabetes into remission, and then use a lower dose of metformin to keep the diabetes in remission.

Q: How do you think this debate be resolved?

I think we will all agree that more surgery should be offered to patients; and that we need to use this combined treatment model more frequently in patients with diabetes, especially for those that would benefit most. However, it is how this cohort of patients will be defined that will provoke further debate.

Q: What do you enjoy doing in your spare time?

I have recently started sailing Flying Fifteens and am currently training to qualify for the World Championships in 2019.

Q: Who do you admire most and why?

Rodin – as a sculpture artist he was able to communicate very complex concepts using the human body, but he did so in a simplistic way that influenced how people thought, thus moving civilization forward.

Obesity Update 2018, an event sponsored by the Society for Endocrinology and the Association for the Study of Obesity, will be held in London, 1 February 2018. Register now to attend.