In a paper just published in BMJ Open, it is reported that the incidence of prediabetes in England increased from 11.6% in 2003 to 35.6% in 2011 (1). Those with prediabetes have an increased risk of developing full blown diabetes. Furthermore vascular complications, nephropathy, retinopathy and neuropathies are more common in people with prediabetes than in individuals who have normal blood glucose levels.
The study is based on information contained in the Health Survey for England, which collected the relevant data in 2003, 2006, 2009 and 2011. The reliable estimate of the average blood glucose levels over the previous 2-3 months can obtained by measuring the percentage of glucose which is attached to the haemoglobin. When this value is above 6.5% the person is considered to have diabetes (Type 2). Values below 5.7% are regarded as “normal”. However if the value is between 5.7 and 6.4% this is prediabetes.
The significance of this study is the extremely rapid increase which has been observed in such a short period. It had already been known that between 1994 and 2009 the incidence of full-blown diabetes had doubled, which is bad news. However this latest information provides convincing evidence that we really do have a major public health crisis on our hands. All the indications are that the position is going to continue to deteriorate. It is crucial to appreciate that those with diabetes may not only suffer from catastrophic conditions such as blindness and limb amputations but also have a much increased risk of heart disease, cancer and Alzheimer’s Disease.
Currently the NHS spends about £10B on the treatment and care of patients with diabetes. Unfortunately there is little success in overcoming the disease. Screening for diabetes does not seem to be effective. In a large study conducted in the East of England it was found that screening of patients with increased risk of diabetes was not associated with any reduction in all-cause, cardiovascular, or diabetes-related mortality over a 10-year period (2). There are also serious questions about the effectiveness of treatments of diabetes to lower the blood glucose. In a meta-analysis of data from 13 randomized controlled trials there was no benefit from intensive glucose lowering in terms of all-cause mortality or deaths from cardiovascular disease.in adults with diabetes (3). Furthermore, an increase in all-cause mortality of 19% cannot be ruled out. Only one study showed a protective effect on myocardial infarction but this was counterbalanced by an increase in total mortality. The authors pointed out that drugs for the treatment of diabetes are being approved on the basis of their effectiveness in lowering blood glucose, despite the fact that there is no evidence based on clinically relevant criteria.
The only logical approach to dealing with this issue is to identify the cause and take appropriate steps to eliminate it. This really should be straight forward. Diabetes is excess glucose in the blood which arises because the body is unable to produce sufficient insulin to cope with it (Type 1) or the diet contains excessive amounts of sugar and carbohydrates which break down to produce the glucose which is absorbed into the blood (Type 2). Type 1 is genetically determined and the incidence has remained constant. It is Type 2 which is responsible for the recent dramatic increases.
All the evidence shows that if the diet can be altered to lower the glucose which enters the blood then the problem will be solved. What is more there is plenty of evidence to confirm that this approach is very effective. Details are available on some of my earlier blogs (4, 5, 6). From a conceptual perspective it is easy to understand. Reduce sugar and refined carbohydrates is all that is required. For most people the foods which contain these constituents are an important source of energy and unless another source is included in the diet, individuals will find it very difficult to comply because they will feel hungry!
However if we look at the advice provide by NICE (7) here is what we find:
- Increase consumption of foods high in fibre, such as wholegrain bread and cereals…
- Choose foods that are lower in fat and saturated fat (SFA), for example, by replacing products high in SFA (such as butter, ghee, some margarines or coconut oil) with versions made with vegetable oils that are high in unsaturated fat, or use low-fat spreads
- Choose skimmed milk or semi-skimmed milk and low fat yoghurts instead of cream and full-fat milk and dairy products
Health professionals should:
“Explain that increasing dietary fibre and reducing fat intake (particularly SFA) can help reduce the chances of developing Type 2 diabetes”
Much of this advice cannot be justified and almost certainly will do more harm than good. Here are my reasons:
- There is a failure to emphasise the critical importance of reducing the sources of glucose
- There is a pre-occupation with reducing fat and with saturated fat which cannot be substantiated (8, 9, 10). In fact many of the individual SFAs are important nutrients
- Many low-fat foods actually have high contents of sugar because the products are formulated by removing fat and replacing it with sugar
- Many of the vegetable oils and margarines are now known to be damaging to health (11).
The utter uselessness of this official advice is illustrated by personal case histories (12). Invariably patients are advised that they have to cut down on fat, as recommended by NICE. As a consequence they have to increase their intake of carbohydrates in the form of bread, potatoes, pasta and rice. Many have found that if they monitor their blood glucose after consuming these foods that it goes up!
Then they do some research with the help of the internet and discover that the carbohydrates should be reduced and that the fat/SFA can be increased without any problem. Within a short time things start to improve and in many cases it is possible to cease all medication.
It is crucial to understand that the glucose-lowering drugs will continue to be effective when the diet is being changed. Hence there is a genuine danger that the blood glucose level will become too low (hypoglycaemia) and it is essential therefore that the medication is adjusted.
- Arch G Manous et al (2014) http://bmjopen.bmj.com/content/4/6/e005002.full
- Rebecca K Simmons et al (2012) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61422-6/fulltext
- Remy Boussageon et al (2011) http://www.bmj.com/content/343/bmj.d4169.pdf%2Bhtml
- NICE (2012) Preventing type 2 diabetes-risk identification and interventions for individuals at high risk: guidance. http://www.nice.org.uk/nicemedia/live/13791/59951/59951.pdf