It is quite obvious that the strategies for dealing with Type 2 Diabetes (T2D) in the UK (and in most other countries) are a complete failure. There is no indication that the disease is under control. In fact, all the projections expect the current rates of increase to be maintained for the foreseeable future.

Latest initiative

In March 2015, NHS England announced the Diabetes Prevention Programme (DPP) which is a joint initiative with Public Health England (PHE) and Diabetes UK (1).The object is to achieve a significant reduction in the number of people with T2D which is expected to be about 4 million if no action is taken. It is claimed that there have been well-designed trials conducted in Finland, the USA, Japan, China and India which show that reductions of up to 60% can be obtained in adults at high risk by means of intervention programmes to encourage changes in lifestyle.

The justification has been developed by NICE. The initial proposals were subject to severe criticisms by specialists in the treatment of T2D (2). For example great emphasis was placed on the importance of weight loss and exercise in spite of limited evidence in support of this strategy. Furthermore this approach was not logical because many of the drugs recommended actually promote weight gain.

As a consequence substantial amendments were made and a revised consultation document was issued. The guidelines are set out in a document entitled “Type 2 diabetes in adults” (3). In addition there is whole raft of appendices.

In view of the importance of developing a policy which will successfully control this key public health issue, it is worth analyzing the DPP carefully.

The Rationale

T2D is defined as a:

 “condition of insufficient insulin production often exacerbated by insulin resistance, the primary treatment for which is weight loss and exercise. Pharmacological measures to increase insulin sensitivity or to increase insulin release can be added to lifestyle interventions, but insulin therapy may eventually be needed by the majority of people as their insulin secretion declines” (4).

Subsequently it goes on to explain that:

“The underlying disorder of type 2 diabetes is usually that of a background of insulin insensitivity where the body is unable to respond to normal levels of insulin, and insulin deficiency where the pancreas is unable to secrete enough insulin to compensate for this resistance. Insulin insensitivity is usually evidenced by excess body weight or obesity, and is exacerbated by overeating and inactivity. It is commonly associated with raised blood pressure, a disturbance of blood lipid levels, and a tendency to develop thrombosis. This combination is often recognised as ‘metabolic syndrome’, and is associated with fatty liver and abdominal adiposity (increased waist circumference). Insulin deficiency is progressive over time, such that the high glucose levels usually worsen relentlessly over a period of 30 years, requiring continued escalation of blood glucose lowering therapy” (3).

These statements are quite remarkable because they are a gross distortion of the science which can only be interpreted as an attempt to provide a justification for using insulin and other drugs as a form of treatment for T2D. As this is the rationale for a massive programme designed to address one of the most pressing public health issues, it must be subjected to detailed scrutiny. In particular, there is a need to understand the role of insulin not only in relation to diabetes (both Type 1 (T1D) and T2D) but also to the other diseases linked to it.

While it is true that T1D is the result of insufficient insulin production because of damage to the pancreas, there seems to be a failure to appreciate that T2D is a totally different disease. The fundamental issue with T2D is excessive levels of glucose in the blood. This in turn stimulates the production of extra insulin which is needed to cope with the large amounts of glucose. While this may be perceived as a requirement for more insulin, it is inevitable that additional insulin will exacerbate the insulin resistance (IR) and cause further ill-health. It really does not take a genius to work out that if there is a reduction in the blood glucose (BG) then there should be a corresponding reduction in the requirement for insulin to be produced. The level of BG is determined by the diet and therefore it follows that alteration to the diet is the obvious solution to the problem.

The Proposed Strategy

Although the main emphasis in the DPP was on the use of drugs to treat T2D there is one chapter which is devoted to “Lifestyle and non-pharmacological management”. This concludes that:

there was little new evidence to warrant any change to previous views in this field. The major consensus-based recommendations from the UK and USA emphasise sensible practical implementation of nutritional advice for people with type 2 diabetes. Management otherwise will concentrate on principles of healthy eating (essentially those for optimal cardiovascular risk protection), and reduction of high levels of free carbohydrate in foods that may cause hyperglycaemia in the presence of defective insulin secretory reserve”.

Here again, note the term “defective insulin secretory reserve” where the underlying assumption seems to be that the body should be able to cope with whatever is thrown at it. Would it not be much more sensible to regard a diet which produced excessive glucose in the blood as toxic? Obviously this question never arose because it is certainly not addressed in the current official recommendations which are to:

“Emphasise advice on healthy balanced eating that is applicable to the general population when providing advice to adults with type 2 diabetes. Encourage high-fibre, low-glycaemic-index sources of carbohydrate in the diet, such as fruit, vegetables, wholegrains and pulses; include low-fat dairy products and oily fish;  and control the intake of foods containing saturated and trans fatty acids”.

It goes on to state that:

“If people are currently gaining weight, weight maintenance is advantageous”.

Finally some suggestions for future research are presented on the grounds that:

“Type 2 diabetes is associated with obesity, and lifestyle interventions including diet and physical activity are thought to be useful in helping to control the condition and improve patient outcomes such as reducing the risk of long-term complications and increasing quality of life. Low carbohydrate diets have been a source of discussion over the past two decades and there is much debate regarding its effectiveness and safety in controlling blood glucose levels, particularly in the longer-term. Specifically, there is little consensus on the optimal intake of daily carbohydrates, where the risk of adverse effects such as hypoglycaemia is minimised. A randomised controlled trial addressing this clinical question would help to provide a better understanding of the effects of low carbohydrate diets on diabetes control and maintenance to inform appropriate management strategies”.

Conclusion

The reasoning here is bizarre. It seems pretty obvious that there has not been any real effort to consider the science and the related issues objectively. IR is a symptom. This is caused by excessive consumption of sugar and carbohydrates. It follows that the way to address the disease is to alter the diet so that the consumption of these constituents is reduced. It is disingenuous to conclude that there is a need for more studies to address this question. In reality there has been more than enough to demonstrate that this approach is effective (6). Why should there be any adverse effects since there are plenty of populations that have consumed low carb diets for generations without any indication of problems? As experience with T1D has shown, hypos are much more likely to occur with high insulin doses, which are necessary with a high carb diet. By contrast, hypos are less frequent on a low carb diet, which incidentally also requires lower doses of insulin, thereby reducing the risks of developing IR.

When it comes to the dietary recommendations, the official government strategy appears to be accepted without debate, which advocates reduced fat and increased carbs. It is no great surprise to discover that those with T2D who follow this advice do not improve and almost certainly deteriorate even further.

This approach also advocates weight loss by calorie reduction. Again this does not work and this topic will be considered in the next blog.

References

  1. http://www.england.nhs.uk/2015/03/12/diabetes-prevention/
  2. http://www.pulsetoday.co.uk/clinical/diabetes/nice-risks-making-itself-a-laughing-stock-over-guidance-on-metformin-alternatives-say-experts/20009139.article#.VdhZxnlRHIU
  3. https://www.nice.org.uk/guidance/gid-cgwave0612/documents/type-2-diabetes-final-scope2
  4. http://www.nice.org.uk/guidance/gid-cgwave0612/resources/type-2-diabetes-full-guideline2
  1. http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Treatment.aspx
  2. http://www.nutritionjrnl.com/article/S0899-9007(14)00332-3/pdf