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?
Body of Evidence 
Diabetes (type 2) is a disease of carbohydrate intolerance and does correct when carbs are restricted, which produces benefits similar to calorie restriction, but without malnutrition.
Here were have a ketogenic (carb-free) “Mediterranean diet” reversing metabolic syndrome in 100% of subjects. http://publicationslist.org/data/pv1peguj/ref-28/SKMD%20and%20MS.pdf
“After the diet all the subjects were free of metabolic syndrome according to the International Diabetes Federation definition, and 100% of them had normal triacylglycerols and high-density lipoprotein cholesterol levels, in spite of the fact that 77.27% of them still had a body mass index of >30 kg=m2”
However it needn’t be a Mediterranean diet by any stretch of the imagination, all that matters is that the diet is nutritionally adequate, very low in carbohydrate.
These two studies are intriguing because they seem to show that dairy fat consumption (indeed ruminant fat in general) gives significant protection against diabetes. One of the major changes in our diets since the 1960s has been huge drops in butter and ruminant fat consumption, this being replaced with either more carbohydrate, and/or highly polyunsaturated vegetable oils.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056495/
http://www.ncbi.nlm.nih.gov/pubmed/23407305
Yes – evidence for benefits of low carb increasingly impressive and and many interesting possibilities of combining it with Med diet or alternate day diet and so on. What will it take for dieticians to recant and officially consign low fat diet to medical scrap heap?
800 kiloCal daily is concentration camp medicine. Unsustainable more than a few months, outside the latter setting.
Ridiculous.
It cannot work in the long term.
Have a look at Lustig’s Fat chance book:
http://www.amazon.com/Fat-Chance-Beating-Against-Processed/dp/159463100X
or at Taubes books, but Lustig is more “scientific” and covers more of the obesity mechanisms. And he treats obese kids.
I suspect , hope that a carb debrived diet would do much better. A mix of Atkins and the mediterranean diet implemented in the Lyon diet Heart Study.
The westernised (using the Western Market products) Mediterranean diet is sustainable for ever (or we would’nt be here). Often misunderstood as fruit fish vegetable bread and olive oil. Not only.
Well, Atkinize the Med Diet (which , again, is not as just olive oil, it is vegetal omega – 3 rich, dairy fat poor, meat reasonable, red meat poor, nut rich or reasonabe.
http://en.wikipedia.org/wiki/Mediterranean_diet
http://circ.ahajournals.org/content/103/13/1823.full
Suppress or drastically decrease all that has a high or medium glycaemic index/load (refined cereals for instance, starches ) accept more good fats (fish, nuts, live and rapeseed oil, goat / sheep cheses).
The Atkins principle (lower than low glycaemic indexes , as much fat as you want) likely makes you thinner, and take out of Atkins what is contra-mediterranean, à la Lyon Diet Heart Study so that yo uprotect your cardiovascular (and cancer) health.
Well I agree there is no proof to what I suggest , but I doubt the med diet alone will suffice in obese persons.
Plus exercise, not for weight (exercise to burn one donut or French frie is undoable by most), but for health.
Agree 800 kg is not sustainable but latest research (February issue of the British Journal of General Practice) found that when a 90 seriously obese people did it for 3 month 30 per cent of them lost 15 to 20 kilos and kept it off for a year with a lot of support. A small earlier study (ref on request) found that a similar diet on a similar group of diabetics allowed a significant number to reverse all their metabolic markers for diabetes. Don’t think Med diet could do that but it is great for every day.
Hi Jerome,
I doubt not it works. But at what expense (suffering, refraining binges, being starved tired, ill tempered, and more) ? I have a gut feeling about this , maybe someone can enlighten me ? The ref ?
Take off starches and sweeties, that may be longer but enough. Yet not proven as far as I know, but I didn’t search Medline recently really.
Well, in 1911, dietitians advocated a no wheat diet, but obviously now we follow the guidelines of the insane (or is it some well meaning pharma company?) and advise to eat as much grain, starch and sugar (fruit) as you can fill your face with. These are modern times and what did they know in 1911 anyway? Every day I see people with diabetes, suggest that they change their diet and lifestyle and within a month (sometimes days) their lives have changed for the better. GP’s never seem to have any information, just a prescription for a medication that will guarantee a deterioration of health, increased medication and no life quality to speak of. Yay for modern times!