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Analysis Too Much Medicine

The epidemic of pre-diabetes: the medicine and the politics

BMJ 2014; 349 doi: (Published 15 July 2014) Cite this as: BMJ 2014;349:g4485

Rapid Response:

Professors John Yudkin and Victor Montori, have explored the evidence and value of pre-diabetes as a category or diagnosis and argue that current definitions risk unnecessary medicalisation and create unsustainable burdens for healthcare systems.(1) This represents, amongst other issues, cause for concern.

How have we reached a point where pre-diabetes is being considered? The role of the diabetic diet is a key issue: Historically dietary recommendations for diabetes were based on low carbohydrate and normal fat consumption, for example: A 1970s UK study of two hundred newly diagnosed, overweight diabetics concluded that control of diabetes in obese patients who respond to diet alone is due to carbohydrate restriction rather than to weight loss, this result was achieved in 80% of the participants. A highly significant statement regarding this research was - They did not start drug treatment until it was clear that diet alone had failed, which was usually after at least four months.(2) This study was led by some of the world’s most eminent diabetologists.

A further 1979 study concluded that in Type 2 diabetes a high carbohydrate diet composed of readily available cereal foods and tuberous vegetables (wholefoods) resulted in lower fasting and preprandial blood glucose concentrations than a standard low carbohydrate diet. (3)

However, by the 1980s national diabetes associations were recommending diets with a substantial amount of carbohydrate and fibre and little fat to improve glycaemic control and reduce the risk factors for ischemic heart disease.(4)(5) No doubt driven by the controversial 'diet heart' hypothesis.

Have the low fat and high carbohydrate diets wreaked havoc within the diabetes epidemic? Fats are a vital component of the human diet and within normal homeostatic function. It should also be borne in mind that without appropriate fats we cannot absorb nutrients such as vitamin D. Unsurprisingly vitamin D is often found to be deficient within the diabetes population. Crucially vitamin D plays an important role in insulin secretion and insulin sensitivity for glucose homeostasis. (6) The balancing role of fat also plays a vital role in the prevention of diabetes complications such as retinopathy and in renal health. Fat consumption also provides satiety within the diet and so may prevent overeating. Carbohydrates are converted to glucose (sugar) by the action of insulin. In a population of people with marked insulin resistance, the high carbohydrate diet approach makes little sense.

The diabetes epidemic has been spread around the world by the adoption of the western type diet and lifestyle as dominant factors. The introduction of highly processed foods and fats contribute to a diet which is destructive to health and promotes pro-inflammatory conditions, such as type 2 diabetes. It has also promoted obesity and, as a consequence, a very lucrative slimming industry. This trend has been compounded by the greed and stealth of the vested interests in the food and drug industries which have substantially benefitted from the diabetes/obesity epidemic.

Recently there has been much controversy over cholesterol (statins) management of people not considered at high risk of cardiovascular disease (Pre-cardiovascular disease?). (7) The article Adverse effects of statins by BMJ editor Fiona Godlee attracted 86 responses, However it appears that concerns raised have been brushed aside. Why the reluctance to honestly review the evidence concerning the role of fat (lipids) within the diet and also the medicalisation of a healthy population? A negative correlation between statin use and diabetes has also been highlighted. (8) Isn’t the treatment of pre-diabetes a similar issue? Where are the meaningful preventative measures? Where is the realistic educational support to help people live a healthy life with fully diagnosed T2DM? World health systems are being crushed under the burden of T2DM. Those diagnosed? with ‘pre-diabetes’ will potentially be medicalised at an earlier date. Including being placed on dubious diets and barely tested drugs. It appears there is nothing in place to ensure that medicalisation will not take place, or indeed the potential prevention of diabetes which represents a golden opportunity.

(1) The epidemic of pre-diabetes: the medicine and the politics John S Yudkin, Victor M Montori,: BMJ 2014;349:g4485
(2) Effect of Carbohydrate Restriction in Obese Diabetics:Relationship of Control to Weight Loss J. R. Wall, D. A. Pyke, W. G. Oakley British Medical Journal, 1973, 1, 577-578
(3) Simpson, R W, et al, British Medical Journal, 1979, 1, 1753.
(4) American Diabetes Association. Nutritional recommendations and principles for individuals with diabetes mellitus. Diabetes Care 1987;10: 126-32.
(5) Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes.Nutritional recommendations for individuals with diabetes mellitus. Diabetes, Nutrition and Metabolism 1988;1:145-9.
(6) Role of vitamin d in insulin secretion and insulin sensitivity for glucose homeostasis. Alvarez JA, Ashraf A. Int J Endocrinol. 2010;2010:351385.
(7) Adverse effects of statins. Fiona Godlee. BMJ 2014;348:g3306
(8) Do statins cause diabetes? Goldstein MR1, Mascitelli L. Curr Diab Rep. 2013 Jun;13(3):381-90. doi: 10.1007/s11892-013-0368-x.

Competing interests: No competing interests

22 July 2014
Jane E Collis
Independent Health Resercher
Kenilworth Warwickshire UK