Trent Ernst, Editor
Is the current ‘glucocentric’ approach to management of type 2 diabetes misguided?
That’s the question the UBC Therapeutics Initiative (TI) asked in a recently released Therapeutics Letter, “
It questions whether the dominant approach to treating Type 2 diabetes, a condition now epidemic in rich countries, is “medically sensible.”
Type 2 diabetes is caused mostly by excessive consumption of carbohydrates, overweight, and lack of exercise.
It also has a strong genetic component. People with modest elevations of blood glucose are rarely symptomatic.
Most treatment is aimed at preventing long-term complications such as heart attacks, strokes, kidney failure, blindness, amputations, and premature death.
Although still widely promoted, glucose control with Type 2 diabetes has not been proven to prevent these problems, says the letter.
Drug therapy aimed at achieving near normal blood glucose (especially with insulin or sulfonylurea drugs) frequently causes symptomatic hypoglycaemia (low blood sugar), which can lead to falls, accidents, and in extreme cases to loss of consciousness.
The Therapeutics Initiative has reviewed recent analyses of scientific evidence from randomized controlled trials (RCT) of diabetes treatment. These show that intensive glucose lowering (“tight control”) does not accomplish the intended benefits of therapy, but does increase the harms.
Metformin, the standard recommended “first line” treatment for Type 2 diabetes, was believed to reduce heart attacks, and even death. But even this conclusion is now questionable because the small experiment on which it was based has never been replicated.
Dr. Charles Helm, is one of a growing number of doctors who believe that lifestyle changes, far more than medication, is key to reducing the cases of type 2 diabetes.
He cites examples of middle-aged patients who recently achieved huge reductions in blood glucose by diet and lifestyle change alone:
“Show me a medication that can get anywhere near to lowering someone from HbA1C (A1C, a measure of blood glucose over time) of 9.2 to 5.9, or from 12.3 to 5.0,” says Helm. “This is what some of my patients have taught me can be achieved with attention to lifestyle changes. I have learned from this and have modified how I discuss Type 2 diabetes with patients, once it is diagnosed.”
Helm admits that this is a far more difficult path, but far more rewarding. “It does take more time, but that is time well spent. I agree that physicians need to be more ‘insulin resistant’”
One of those patients who has benefited from lifestyle changes is Trent Ernst, Editor of this paper and author of this article.
He says that, while he never really considered himself out of shape, he was definitely overweight and started to notice symptoms consistent with Type 2 Diabetes about three years ago.
“I tell people that type 2 diabetes is just your body telling you that you have too much body,” says Ernst.
By changing his diet and exercising regularly, Ernst was able to noticeably change his blood sugar levels. “I was on Metformin for about a year,” he says. “But after losing about eighty pounds, I was able to manage my blood sugar levels to something more normal.
A recent analysis from the United States shows that the typical patient with non-symptomatic Type 2 diabetes “cannot expect to benefit from glucose-oriented treatment over a lifetime.”
The U.S. researchers concluded that “Current evidence strongly supports that there is a potential epidemic of overtreatment with antihyperglycemic therapies in diabetes.”
Because of this, the UBC scientists are calling for a new international research effort to establish how health professionals should treat epidemic Type 2 diabetes.
Dr. Jim Wright, UBC TI Co-Director and Professor in UBC’s Department of Anaesthesiology, Pharmacology & Therapeutics emphasizes that doctors still have little idea what their glucose-lowering treatments accomplish:
“Type 2 diabetes is very different from Type 1, where insulin is life-saving,” says Wright. “For Type 2 diabetes, we know that some past treatments caused more harm than good. We are still causing a lot of unnecessary harm to patients– even with the best of intentions. To do better, we need independent research sponsored with public funds that asks the right questions. This will require a new way of thinking about how to design research for major long term public health issues so that we get results we can trust and implement to improve health.”
Dr. Tom Perry, a general internist and clinical pharmacologist with the TI, says clinical practice guidelines tend to foster unwarranted confidence in current and new therapies: “We all want to help our patients, but the history of medicine shows that we exaggerate how much good we are do and tend to minimize the harm. Massive emphasis on drug therapy is diverting us from preventive approaches like regular physical exercise and dietary moderation that are more likely to benefit people long term.”
Dr. Lance De Foa, an Ontario doctor, recently coined the term “insulin resistant physicians”, noting that pressure to prescribe insulin (and other drugs) in Type 2 diabetes is not free of commercial influence by makers of insulin: “I think we rural doctors should be the ones who are “insulin resistant” so we can direct our patients to treatments that will reduce their own insulin needs, and get them off the list of meds. Of course it is easier and takes much less time to prescribe a drug than to explain why low carbohydrate diet and exercise are crucial. Good medical care takes MUCH more time but I find that many patients are then quite willing to do what they need to get healthy instead of sliding down the slope towards more and more complex drug therapy. We need to be wary of those who fund the ‘prescribe my drugs’ guidelines and seek to ‘inform’ policy makers.”