Diabetes: ‘awareness’ vs action

The endless parade of ‘disease awareness’ days, weeks and months rolls on. This time it’s diabetes’ turn to twirl the baton, with Diabetes Australia declaring 8-14 July National Diabetes Week. Diabetes Australia summarises the mission of National Diabetes Week, and the broader ‘It’s About Time’ Campaign of which it forms part, as follows:

“Diabetes Australia’s ‘It’s About Time’ campaign aims to raise awareness about the importance of early detection and early treatment for all types of diabetes.”

They go on to state that both type 1 diabetes and type 2 diabetes continue to go undiagnosed in many Australians who suffer from these conditions, and that

“The delay in diagnosis is putting many people at risk of major life threatening health problems.”

They imply that earlier diagnosis of diabetes and and treatment of diabetes will reduce the death toll from these terrible diseases:

“‘It’s About Time’ we detected all types of diabetes earlier and save lives.”

I’m all for saving lives. Diabetes is a terrible disease – I lost my Dad to it, he lost his father to it, my mother lost her mother to it, and my mother’s sister and oldest daughter suffer from it. But I have serious doubts about the ability of ‘awareness raising’ campaigns to achieve any useful outcomes for diabetics, whether undiagnosed or diagnosed.

It’s obviously important for people to know whether they have diabetes. The problem is the standard-of-care treatment they’re given once they’re diagnosed.

Newly-diagnosed diabetics are usually referred to dietitians for nutritional advice. In the case of type 1 diabetics, that advice is primarily about balancing their carbohydrate intake with insulin, to avoid either elevated blood sugar or excessively low blood sugar (‘hypos’). Type 2s will sometimes be given a trial of dietary intervention, but the advice they are given (summarised below) rarely improves their condition sufficiently to avoid having to go on diabetes medication.

Dietary advice from Diabetes Australia's 'What should I eat?' page

Eat a diet lower in fat, particularly saturated fat.

What does 'lower' mean? Vague advice like this does more harm than good. If a diabetic cuts down their cheeseburger intake from 3 per day to 2 per day, they could rightly argue that they're eating a diet lower in saturated fat than they were before, but such modest change won't save them from diabetic complications and an early death.

Limit foods high in energy such as take away foods, sweet biscuits, cakes, sugar sweetened drinks and fruit juice, lollies, chocolate and savoury snacks.

Again, 'limit' is a vague term that is completely open to individual interpretation. Studies of how 'moderation' is interpreted indicate that when people enjoy a food, they describe their consumption of it as 'moderate', no matter how much they eat! If Diabetes Australia really wanted to save lives, they'd give it to diabetics straight: if you want to avoid the tragic complications of diabetes, or you want to go further and become an ex-type 2 diabetic (i.e. get your HbA1c back in the normal range and keep it that way, without medication), don't eat junk food.

Choose lean meat and trim any fat off before cooking. Remove the skin from chicken, duck and other poultry (where possible, before cooking).

Even meat with no visible fat contains at least 20% fat by calories, and the most successful diets for reversing diabetes contain 10% fat or less (see below). Since multiple epidemiological studies have found that eating meat raises the risk of developing diabetes, why on earth would anyone advise someone who already has it to eat meat?

Limit the use of processed deli meats (devon/polony/fritz/luncheon meat, chicken loaf, salami etc) and sausages.

Diabetics are at increased risk of colorectal cancer, and are more likely to die from it than nondiabetics. Processed meats are a Group 1 carcinogen - that is, they definitely cause cancer in humans, and the form of cancer they are most strongly associated with is colorectal cancer. Given the World Cancer Research Fund's assessment that "no level of intake can confidently be associated with a lack of risk", diabetics should be told the truth - any intake of processed meat is unsafe, especially for them.

Eat polyunsaturated margarines, sunflower, safflower, soybean, corn, cottonseed, grapeseed and sesame oils.

While polyunsaturated fats appear less harmful to diabetics than saturated fats, to repeat, the most effective dietary intervention for diabetics is a low fat plant-based diet, containing no added oils or fats. There are no benefits to adding extracted oils or fats to the diet; whole plant foods contain all the essential fatty acids that we require.

For some people, a lower carbohydrate diet may help with diabetes management. Protein does not break down into glucose, so it does not directly raise blood glucose levels.

Low carbohydrate diets based on animal foods increase the risk of developing diabetes. The most successful interventions for both type 1 and type 2 diabetes are high in unrefined carbohydrate and fibre - see here, here. A high carbohydrate diet improves multiple measures of diabetic control including haemoglobin A1c, fasting plasma glucose decreased and insulin sensitivity, in contrast to high protein intake.

Lentils and legumes contain carbohydrate and therefore have an effect on blood glucose levels but should still be included as part of a healthy diet.

The way that Diabetes Australia frames its advice manages to make it sound as if diabetics should be cautious about eating legumes, when in reality, legumes are one of the most beneficial food groups for preventing and managing diabetes - they reduce the risk of developing metabolic syndrome (a collection of factors that raise the risk of developing diabetes), improve metabolic syndrome in those who already have it, and enhance insulin sensitivity not just at the time they're eaten, but at the subsequent meal.

One diet does not fit all; there is no diet that works for everyone.

Epidemiological and clinical research clearly indicates that a plant-based diet reduces the risk of developing diabetes in the first place, and is far more effective than the standard dietary recommendations at managing and even reversing diabetes.

The tragedy is that when type 2 diabetics are given dietary advice that fails to control their condition, they’re put on medications that – contrary to Diabetes Australia’s claims – do not save lives.

Metformin (Glucophage, Diabex, Diaformin) is the first line treatment for diabetes. A 2012 meta-analysis found

“no evidence for benefits of metformin in terms of all-cause or cardiovascular mortality and all diabetes macrovascular complications”.

In other words, metformin didn’t prevent diabetics from dying early, or developing or dying from heart disease. In fact, some studies indicate that metformin may even increase all-cause mortality by up to 31% and increase cardiovascular mortality by up to 64%.
Furthermore, the authors state,

“metformin has no proven efficacy against the occurrence of microvascular complications.”

The microvascular complications of diabetes are retinopathy, nephropathy and neuropathy (diabetic eye, kidney and nerve disease respectively).

The authors of the metformin meta-analysis point out that other classes of diabetes drugs are even more dangerous:

First-generation sulphonylureas such as chlorpropamide (Diabinese) and tolbutamide (Orinase) increase all-cause mortality (the risk of dying from any cause) by 24%–61%), while second-generation sulphonylureas such as glipizide (Glucotrol), glyburide (Diabeta, Micronase, and Glynase PresTab), and glimepiride (Amaryl) increase the risk of congestive heart failure by 18%-30%.
Insulin therapy also increases all-cause mortality, especially in patients with heart failure.
The combination of sulphonylurea drugs with insulin therapy may increase the risk of dying from cancer mortality.
The thiazolidinedione drug rosiglitazone (Avandia) was pulled from the market across Europe, the UK, India, New Zealand and South Africa because it increased the risk of heart attack and death; it is still available in Australia. Pioglitazone (Actos) causes weight gain and increases the risk of congestive heart failure, making its benefit/risk ratio unclear.

The problem with diabetes drugs is that while they are very good at reducing blood sugar levels, that doesn’t translate to improved health outcomes or longer lives for diabetics. And the more drugs used, the worse the outcomes:

Intensive glucose control (the prescription of either higher doses and/or multiple types of diabetes drugs to lower diabetics’ blood glucose level was found to have no effect on their risk of dying or suffering major cardiovascular events (such as heart attacks) or microvascular complications compared to standard medication regimes, but there was a higher rate of adverse events (mostly hypoglycaemia) in the intensive treatment group.

In another study, intensive glucose control for 3.5 years increased mortality by 22% compared to standard treatment and did not significantly reduce major cardiovascular events.

The editorial team of the prestigious medical journal Lancet summed up the situation perfectly:

“Medicine might be winning the battle of glucose control, but is losing the war against diabetes… increasing evidence suggests that glucocentric treatment [i.e. treating diabetics with drugs that lower their blood glucose level] might not result in better overall outcomes.”

In stark contrast, plant-based diets not only reduce blood glucose level and HbA1c, but also decrease all-cause mortality; reduce the risk of becoming obese; cut the risk of developing metabolic syndrome and type 2 diabetes in the first place by about one half; slash the risk of coronary heart disease events (the leading cause of death in diabetics) by roughly 40% and the risk of stroke by 29%.

Doesn’t that sound like a better deal to you than a lifetime of side effect-inducing medication that gives you better numbers on blood tests, but doesn’t treat your diabetes in any meaningful way?