Who’s responsible for our diabetes/obesity epidemic? Is it those fat lazy bastards who eat crap food and sit on the couch all day or is it the drug companies that spend billions researching and marketing drugs of limited effectiveness or dubious safety or is the government that allows commercial interest to create a food supply that makes ballooning waistlines inevitable?
Personal failing – the fat bastards – is the favourite villain; hence all those diet books and individually targeted weight loss programs. But two big studies out this month point the finger firmly in the direction of government that is too small and pharma that is too big.
Big government is out of favour these days but top down control can have a remarkable effect on the number of people getting diabetes and the number of deaths. This is what happened in Cuba nearly 20 years ago according to a fascinating analysis in the BMJ this week by Dr Manuel Franco of the University of Alcala. In 1991 the whole Cuban population was de facto put on a calorie restricted diet by an American trade embargo.
Both food and fuel supplies plummeted. The nation’s daily calorie intake dropped from 3000 to 2000 and motorised transport ground to a halt. The government ensured that everyone had a basic diet and imported 1.5 million bicycles from China to make up for the lack of cars and buses.
Diabetes cases declined sharply
As a result Cubans lost an average of five kilos in four years and the percentage of the population who were physically active shot up from 30% to 80%.
The health benefits were impressive. New cases of diabetes declined sharply and within a few years the number of deaths from the disease had dropped by 40%. (If a one-off treatment with a drug could do that, would it be marketed? This is not cynical question; lack of profitability is the official reason why there are almost no new antibiotics in development, despite a growing need.)
Still unconvinced there is a direct and reversible link between diabetes and weight and exercise? The study tells what happened when conditions improved and average calorie intake rose and exercise dropped off. As people’s weight increased, the number of diabetes cases increased in parallel, as did the number of deaths.
“So what?” you might say. “We know that eating less and moving more is the key to lowering diabetes risk.” To which the obvious reply is: “So why is the UK spending over 600 million pounds a year, and rising, on drugs, while world-wide, billions are spent on research and studies designed to develop new ones and bring them to market?”
Diabetes trials ignore prevention
This is not just rhetoric. Another recent study has found that a mere 10% of diabetes trials worldwide deal with prevention or behavioural change. This compares with 66% that focus on drug therapy. (This is making exactly the same point made by a cancer researcher in my recent post on the Silver Bullet. Drugs which play a relatively small part in cancer treatment get the lion’s share of the research budget. A process I’ve called Pharma Fleece.)
Now it turns out the same thing goes on with diabetes. Even worse, as evidence based medicine the trials are pretty useless. “The majority of diabetes related trials,” says lead author Dr Jennifer Green of Duke University Medical Centre in North Carolina “have small numbers, exclude the young and the old, involve drugs and only last a short time.”
For instance just 1% involved patients over 65 and a mere 1.5% answered the two vital questions: will the drug make me live any longer and will it cut my risk of heart problems?
Diet and exercise not taken seriously
As the Cuba study showed, you don’t need a very expensive drug regime to prevent or even reverse diabetes. Of course drugs have a role but the lifestyle approach is far safer and more effective. The Cuban experience is obviously not directly applicable to the UK. But if we had a genuinely evidence based medical system, we’d be properly funding research to find the best ways to achieve the same results.
But funding for lifestyle solutions is notoriously thin on the ground. In the last two years two UK trials have been published showing that it is possible to reverse diabetes by putting people on an 800 calorie, nutrition boosted liquid formula diet for a few months. Yet so far Diabetes UK is still wondering whether to fund a bigger follow-up trial.
Given the massive personal and financial cost of obesity and diabetes, can we really afford to keep marginalising something that we know works? There has been plenty of talk, but little action, on the need for tougher government action on our food supply. But how about another big-government type action?
What about an obligation for any charity that raises money for lifestyle disorders such as diabetes, heart disease and Alzheimer’s, that at least 25% of their research budget is spent on lifestyle treatments? Does anyone know what proportion any of them spend at the moment?