On Tuesday the British Journal of Medicine published an analysis that stated, “The ADA (American Diabetes Association) recommends treating pre-diabetes with metformin, but the majority of people would receive absolutely no benefit.” At first glance I assumed the experts considered diagnosing pre-diabetes a waste of time and resources. While vehemently disagreeing with that notion, I read the review and started to appreciate a more nuanced message. I’m taking the time to tease apart the issues.
Too often medical experts seem stuck in a silo. Current medical institutions and professional organizations tend to reinforce the division of labor: some dedicated to diabetes, others to cardiovascular disease, others to the gut, ad infinitum. In a world of specialists, patients are challenged to navigate the messy world of poor metabolic health where such artificial boundaries don’t exist. In this case, a narrow focus on diabetes misses the more complicated connections between too much insulin and blood sugar driving a state of inflammation. Many health problems stem from this poor metabolic state, including a wide range of diagnosable diseases ranging from autoimmune conditions to heart disease and cancer. So a first, a little background information and commentary.
SOME PERSPECTIVE REGARDING BLOOD GLUCOSE AND DIABETES
1. Diabetes is not the only problem linked to elevated blood sugar. Blood sugar typically rises only after the pancreas can’t keep up insulin production. Elevated insulin is called hyperinsulinemia and it drives weight gain, inflammation and a host of other metabolic problems. Its rather short sighted to consider a diabetes–determined when blood sugars reach an arbitrary number– as the only negative outcome of ‘pre-diabetes’.
2. Of course pharmaceutical companies are going to jump on the bandwagon to capitalize on the opportunity. I challenge both doctors and regulators to step in and stop this nonsense. No drug is likely to override a poor diet and lack of physical activity. We should stop pretending the remedy to poor metabolic health can be easily found in a new and expensive little pill.
3. Hyperinsulinemia negatively impacts energy metabolism decades before blood sugars start to rise. Instead of delaying diagnosis, we should be assessing for metabolic health even earlier in the curve, and provide meaningful nutrition and lifestyle education, counseling before things get worse. In some cases metformin can be a helpful adjunct to medical nutrition therapy far before blood glucose levels start to rise.
FINANCIAL, SOCIAL AND EMOTIONAL COSTS
Authorities charge that the diagnosis of diabetes “carries great financial, social and emotional costs.” I agree. A diagnosis of diabetes both shocks and awes. I sit with clients as they process the enormity of the task at hand, often so overwhelmed it is difficult to process the most basic steps of self care. But the debilitating stigma and costs most likely lay at the feet of our ham handed labels and delivery of information.
Too many in the medical community play off a patient’s fears to inspire compliance. Public health messages address the worst of possibilities, under the grand illusion that the only way to get our attention is to scare the wits out of us. The pharmaceutical industry continues to develop and market yet another product to capitalize on real and not so real medical conditions. None of these approaches is likely to encourage the meaningful lifestyle change patients need to embrace in order to clean up the metabolic mess.
ARE WE TREATING DISEASE OR THE NATURAL CONSEQUENCE OF AN INDULGENT ENVIRONMENT?
The BMJ analysis quotes co-author Victor Montori, Professor of Medicine at the Mayo Clinic, “Healthy diet and physical activity remain the best ways to prevent and to tackle diabetes.” I agree, however that not how the system currently works. Instead of pumping even more of our precious medical resources into the lap of the pharmaceutical industry and medical technologies, let’s try something truly novel: adequate attention to diet and lifestyle.
Current diagnosis and treatment protocols mostly focus on assessing blood glucose levels, measuring the outcome rather than paying attention to the factors that influence the outcome. How many health care dollars are spent diagnosimg and monitoring glucose compared to efforts directed at helping patients manage change? It seems that most of my clients are readily reimbursed for lab tests and physician check ups, but minimal resources are dedicated to the actual education and counseling needed to address the gaping chasm separating knowledge and behavior. It’s time to turn our approach inside out. Health care providers need an opportunity to give far more attention to the process in order to more effectively impact the outcome.
Ultimately, we need meaningful nutrition education in the community and access to effective medical nutrition therapy in the clinic. Here are a few suggestions to get us on our way:
IN THE MEDICAL WORLD
- Medicare and private insurance companies need to consider reimbursing nutrition counseling before the disease triggers the worse possible conditions. Treating diabetes complications is important, but often too late in the process to meaningfully change a patient’s metabolic tangent.
- Physicians will need to learn how to refer to dietitians consistently so patients can adopt a better approach to food and other lifestyle parameters. Currently most of my patients ask for a referral, not the other way around.
- Patients will need to step up and develop the awareness and skills to manage an ever more complicated food environment. Expecting the food supply to suddenly become healthier is little more than wishful thinking.
- Society in general needs to allow adequate time, energy and resources for food’s rightful place.
- Everyone who touches food needs to recognize that they are either part of the problem or part of the solution. Most establishments that sell or serve food should focus on providing a range of options and reasonable portions.
- Parents will need to teach their children how to self soothe without food, and the rest of us need to continue to refine those skills at every stage of our life.
The opportunity is ours to step up and help create an approach to food that works for all of us. What can you do?