by Marion Nestle
Aug 20 2007

Type 2 Diabetes is Now Controversial?

Today’s New York Times has a front page story by Gina Kolata, who seems to make a career of taking contrary positions on commonly held ideas about health matters. This time, she takes on common understanding of type 2 diabetes. Her article appears to argue that people with type 2 diabetes do not need to worry nearly as much about high blood sugar as they do about high blood cholesterol, that they need a mountain of drugs to stay healthy, that obesity isn’t really related to this condition (genetics counts more), and that rates of type 2 diabetes are not increasing, anyway (it’s just being diagnosed more frequently). Statisticians are unlikely ever to agree on the numbers but type 2 diabetes is the best reason I can think of to follow my “eat less, move more” mantra. Type 2 diabetes is a largely preventable condition. Yes, only small percentage of overweight individuals will develop type 2 diabetes, but the probability of getting it increases with increasing body weight. And if you look at the body weights of people who have been diagnosed with type 2 diabetes, most of them–95% in some studies–are overweight. It doesn’t take much of eating less and moving more to prevent or resolve symptoms. And that works for high blood cholesterol, as well.  Doesn’t doing that seem better than being tied to a lifetime of pharmaceuticals? And what about type 2 diabetes in young children? Isn’t type 2 diabetes something that everyone ought to be trying to prevent? I wrote about these issues in an editorial in the American Journal of Public Health a couple of years ago. Read the references to it and see how they compare to the this-won’t-work attitude expressed in Gina Kolata’s article. Will her article help clear up public confusion about how to approach chronic diseases related to diet and activity levels? Do weigh in on this one.

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  • As with most of Gina Kolata’s articles, I was very disappointed by her suggestion that cholesterol control is more important than good, tight blood sugar control.

    As someone who has T2 diabetes, which my doctors completely missed diagnosing (perhaps for more than a decade) precisely because I am not obese (5’4″ @ 125 lbs) and don’t “fit the profile”), I am shocked at the dangerous advice and info out there for diabetics, both from the medical community and in the media.

    The research (which seems to filter down oh so slowly) is strongly suggesting that T2 diabetes is largely genetic in origin, with epigenetic causes as well (gene switching in the fetus due to things such as the mother’s diet and environmental exposures). The low fat, high carb diet, modern lifestyles, and environmental exposures express the genetic code. In fact, many researchers are of the opinion that the obesity is because of the diabetes, not the other way around.

    I know that for me, my weight is very sensitive to my blood sugar levels. And I can achieve normal blood sugar levels without drugs or insulin, by eating more natural fat and protein with non-starchy vegetables and restricting carbohydrates, *no*t by eating less.

    That is opposite of the conventional T2 Diabetes advice for the past few decades (but it *was* conventional advice before the low fat hysteria hit). Just eating less just doesn’t do it — because the advice to eat less usually includes advice to eat less of the foods that *don’t* raise blood sugar (natural fats and animal proteins) and *more* of the sugars and starches that do raise it (non-fat dairy, grains, legumes). Blood sugar doesn’t have to be very high on a day in/day out basis to kill off beta cells and inflict cellular damage throughout the body (glycosylation – sort of like tarring the cells with burnt sugar).

    Rather than getting bad advice from Ms. Kolata & the NYT, a better source of advice is What They Don’t Tell You About Diabetes, a blog that distilled the research of the day on diabetes. The info on that site made the difference between me suspecting my blood sugar wasn’t normal and having the tools to get my doctors to actively check it out and delaying the diagnosis another decade when it was too obvious to miss.

  • One more thing that is glossed over in most media reports. One in five T2 diabetics is not overweight. 20%, which while a minority, is not insignificant. In my experience having trouble getting my doctors to seriously consider that my glucose metabolism was impaired, I have to wonder if the rates of non-obese diabetics aren’t even higher, because doctors are not screening for diabetes well enough in normal weight individuals. Thin does not necessarily mean healthy, especially after mid-life. Most doctors use the fasting blood glucose test to screen for diabetes, which is completely inadequate, as fasting blood sugar is often the last indicator to become abnormal. It is far better to test post prandial, that is, after a meal containing carbohydrates. That’s when the real damage is done. Even better is a 3, 4 or 5 hour Oral Glucose Tolerance Test (OGTT) with simultaneous insulin levels, but it is time-consuming and more costly so most don’t use anymore as a cost-saaving measure (compare that to advanced diabetes treatment costs!!!). But PP glucose or GTT is a far better indication of how the body is handling glucose and producing insulin. I had to insist on the GTT with my doctor and he was shocked at the results afterward. He and the endocrinologist both said they never would have expected the abnormal result by looking at me (but that is because I have been already managing my weight and blood sugar with a carb restricted diet and and a personal glucose meter, so my routine lab tests are in the high normal range, which doesn’t raise an eyebrow). But a test after glucose tells the real story.

    I only hope that the decade+ of high carb, low fat intake didn’t damage my cells, especially my beta cells, to the point that permanent damage is done. The endo suspects that my insulin production already is not as good as it should be.

    Interestingly enough, about 6 or 7 years ago (during my bread machine phase), my dentist had some concerns about my gums looking and behaving “diabetic” (he knew of my history of gestational diabetes, too) and he suggested it be checked out. My doc did a fasting glucose test and said I was fine. Now I know otherwise.

  • Bix

    I agree with everything Anna said. (She said it so well.) I especially think that a postprandial reading is more telling than a fasting reading – the one docs depend on for screening.

    I think it would be wonderful (and a goal to shoot for) if insurance companies covered the cost of a home glucose meter, and strips, for those with pre-diabetes conditions, like impaired glucose tolerance. Of course, we need to find those IGT individuals first!

  • elfling

    I also want to agree with Anna here about the importance of not overemphasizing the obesity == diabetes connection, and that skinny, active people with no genetic history, as my father is, can also end up with it. I’m seeing a real tendency for people to think of diabetes as a disease only of sloth and moral failure, and no recognition at all among the public that people who appear to be healthy with healthy lifestyles also get diabetes.

    Of course, now I do have a genetic link, so I figure it’s just a matter of time. Meanwhile, I’ll eat right and exercise as best I can.

  • These are such helpful comments. I wish everyone confused about what to do about diabetes could read them. Standard advice applies to populations and may or may not apply to individuals. But eating healthfully makes sense for everyone. The sooner people figure out how to do that, the easier it is. Thanks so much for making those useful points.

  • Michael

    Anna: It’s possible that you may have been misdiagnosed as a result of an artifact of the interface between your diet and the test. The National Diabetes Data Group and WHO guidelines say that the OGTT should be performed in people who have been consuming at least 150 (and some sources say 250!) grams of carbohydrate a day:

    This is because people whose systems have been acclimated to a low-carbohydrate diet tend to adjust by reducing insulin output and inducing some physiological (not pathological) insulin resistance to ensure glucose delivery to the brain, and thus don’t tolerate a large bolus of glucose suddenly shooting into their arms:

    To be sure that you’re not receiving medical treatment for a phantom condition, you might consider and discuss with your doctor temporarily consuming 150+ grams of carb a day, just for a week, and getting re-tested.

  • There’s certainly a great deal to find out about this issue. I really like all of the points you’ve

  • Eat less is not a good message. Eat more whole foods that are less calorie dense is a good one. Fat actually blocks glycogen getting into cells so fat is the problem in t2. See Dr McDougall for more info. Genetics is a cop out and funny how it’s highest in western countries.