Diabetes. Diet goes head to head with drug. Winner is….

Diabetes Day held last Friday had its priorities all wrong. Rather than calling for more innovative drug treatments its goal should have been to explore why diabetics continue to be treated by a system that ignores patients’ wishes and allows ineffective and dangerous treatments to proliferate, while safe and effective ones languish for lack of earning potential.

If that sounds mad and harsh consider the case of two treatments; one actual and the other currently just a twinkle in the eyes of a few visionary doctors but of great and growing interest to hundreds of thousands of diabetic patients.

The relatively new licensed drug – Farxiga (dapagliflozin) – uses a new mechanism to lower blood glucose – blocking a process in the kidneys – but it is not particularly effective. It does cause a small amount of weight loss, usually beneficial for diabetics, but its other side effects include a couple of cancers, a form of dehydration that can require rapid hospitalisation, kidney problems as well as considerably raising your chances of developing a genital fungal infection.

Almost no damaging side effects

Contrast that option with a very low carbohydrate high fat diet which is more effective at getting blood sugar down and keeping it controlled, and which also has a number of beneficial side effects such as impressive weight loss, lowered cholesterol and better liver function. Damaging side -effects are virtually non-existent and many patients are able to cut their drug use after a few months and some say they have become diabetes free.

The obvious question this prompts is: Given that almost everyone would prefer to be treated with the diet, why are only drugs regularly available at your local GP? Why in fact is the NHS spending just over a million pounds on this particular one and around 600 million on all of them?

Of course medical treatment shouldn’t be decided by popularity polling but there are good reasons for thinking that a genuinely evidence based system wouldn’t result in 17 or more expensive trials being run on Farxiga , while the diet is essentially ignored as a treatment or as a topic for research. This in turn allows claims such as the ones I have just been making to be dismissed as anecdotal, unproven or conflicting, followed by a call for more research which is unlikely to ever be funded.

More fat but less cholesterol

A good example of the sort of promising small scale studies that have been done is one run by a pioneering GP called Dr David Unwin that was published last year. There is an account of it in a new post on HealthInsightUK (http://healthinsightuk.org/2014/11/13/high-fat-low-carb-diet-for-diabetes-a-gps-tale/). It involved 19 type 2 diabetic patients being treated in Dr Unwin’s practice who were put on a low carb diet plus regular educational and support sessions. After 7 months only one had dropped out, of the rest all had significant weight loss (average 8.63 Kg) and the average HbA1c was down from 50.68 (6.7%) to 39.9 (5.7%).

What’s more even though the patients were eating much more fat than they had been previously, their cholesterol levels dropped, which is curious given that a lot of fat is supposed to raise cholesterol. Also interesting was that liver function improved for nearly all participants; that is generally considered something that is principally affected by alcohol. (For more details why the low carb diet makes sense with diabetes see http://healthinsightuk.org/2014/08/31/twelve-reasons-why-diabetes-charities-should-ditch-the-low-fat-diet-and-recommend-low-carbs/)

So lots of boxes ticked for diabetic patients and many of them reduced their intake of the regular diabetes drugs. By way of contrast and to support my tirade it is worth going into a bit more details about what is involved with the drug Farxiga.

The independent drug evaluation web site “Worst Pills, Best Pills”, which has an impressive record of spotting problems with drugs, advises against using Farxiga , saying: ‘Patients should not use the drug because it poses serious risks including possible risks of cancer, which outweigh its modest benefits.’ (http://www.worstpills.org/ but it needs a subscription)

Trials don’t deliver what patients want to know

Many of the problems stem from the fact that it blocks a mechanism in the kidneys that allows beneficial substances – such as the important energy source glucose – to be recycled rather than being peed out with the urine.

It was approved solely on the basis that it lowered blood glucose. (This is similar to licencing requirements for other drugs such as those that bring down cholesterol. That’s all they have to show they can do.)

However there are a number of things other than the ability to bring down blood sugar that diabetic patients want to know about when deciding whether to go on a new treatment. For instance, does it improve or reduce diabetic complications (blindness, heart disease, kidney failure and amputation of the feet)? But as ‘Worst Pills’ points out: None of the randomised control trials that evaluated dapagliflozin were designed specifically to measure such clinically meaningful outcomes.’

So why do we put up with a system that claims to be delivering evidence based medicine but doesn’t test many of the things patients want to know about a drug? What’s more, most of the drugs it licences have side effects that are more or less damaging – from cancer to genital fungal disease, while those it excludes or ignores often have side effects that are beneficial such as weight loss or improved liver function.

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Comments

  1. Thank you for the reply Jerome and the comments about epilepsy. My friend – one of those joined by her clinic – tired to contact one of the paediatric dieticians who specialises in low carbing and helps children with epilepsy, she wouldn’t or maybe couldn’t help.
    Luckily I’ve found a fantastic group of people on Facebook who are supportive, follow the new science behind food (Bernstein, Lustig, Taubes, Eenfeldt et al) and keep they kids’ HbA1c’s in the 5 range, with their kids having bags of energy, growing well physically and mentally whilst eating great foods. But is it right this is my best place to go for advice when there’s a nation of NHS dieticians at my disposal?

  2. Great article, fully agree with the points made.
    As a parent of a Type 1 I am struggling with getting advice/support from my child’s dietician, advice about reducing carbs without risking growth or health. All they want to do is help us carb count (my daughter’s an expert already thanks) or teach us which carbohydrates are better for her (again we know this). The big problem here is that my kid quite correctly wonders how I can be right about lower (not low) carbing if the health care system disagrees with me; without her buy in it’s very difficult and so the rollercoaster of blood glucose levels continues.
    Other parents of Type 1 kids who follow a lower-carb way of life are being hounded by their clinics and feel like social services may come knocking soon, whereas there would be no problems if they fed their kid pizza/pasta every night.
    This state of affairs seems so very wrong.

    • Your points make it horribly clear just how illogical the current system is. I wonder if Dr Unwin has any suggestions as a GP who must encounter something similar in his professional capacity.
      A thought which is a bit off in the left field. The low carb diet is official approved for the treatment of childhood epilepsy and there is an organisation called Mathews Friend which has dieticians who are specially trained to deliver a low carb diet to children.
      I appreciate that epilepsy is not the same as Type 1 diabetes but it does show that the diet is effective in protecting neurones and it is clearly effective in reducing blood glucose. It also show that the diet is safe in the long term for children and has been accepted by the NHS for another indication. It is quite common for drugs licenced for one purpose to be used without further trial “off label” if the doctor believes there is a good scientific case for it. I see no reason why the same logic should not be applied to a clinically approve diet.

  3. Dr Charlie, a biochemist says:

    PhilT – I would whole-heartedly agree with you but I would go much further particularly regarding Type 2.

    The initial response of a medic if someone has a high A1c is to put them on a drug to lower their blood glucose. Then the diabetic nurse thinks – ah there is now a danger that the blood glucose levels will drop to a dangerous level so the patient must go on a high carb diet to prevent this.
    The net result is the A1c goes up to above 7% in old money and the blood glucose enters the danger level resulting over time in the major damage to blood vessels in the eye, kidney, heart and periphery.

    The medic thinks Type 2 is a progressive disease – and because of this treatment – it is.
    Who would think that a sensible solution would be to propose to a person suffering from lead poisoning that they should carry on with consuming the poison but take a drug that attempted to remove the lead from the body? Of course, no one would – the sensible thing is to stop eating the material that contains the lead. Yet when people see a medic with glucose poisoning that is exactly what happens.

    Fortunately for some people in the States, some medics can and do recommend a low carb diet so that their patient’s blood sugar level drops to near normal. Dr Eric Westman recently was recorded at a conference outlining the rationale – https://www.youtube.com/watch?v=SCGDAwp-y0o
    He does make the point that someone taking glucose lowering drugs should seek medical advice when going on a low carb diet because of the dangers of becoming hypoglycemic – although, sadly, I’m not sure whether anyone would easily find a medic who would be cooperative in Britain.

    • Dr Charlie, that’s one of the most cogent explanations I’ve seen, and I read a lot about this stuff. Lead poisoning, I love it.

  4. The NHS could save money on its prevailing “eat carbs and back-titrate with insulin” mantra – less carbs eaten = less insulin injected into Type 1 diabetics.

  5. Dr Charlie, a biochemist says:

    Excellent article – many congratulations.

    I’ve got a horrible feeling that I’m about to attempt to teach granny how to suck eggs – but it helps me get it off my chest, so I hope you forgive me taking up space.

    The diabetes drugs seem to target different systems for reducing blood glucose. However, one would think that the first and most simple thing to try would be to lower the consumption of foodstuffs that the body can rapidly breakdown to glucose ie sucrose (table sugar) and starch (bread, pasta, pastry, cake, breakfast cereals, etc, etc) – especially when it is thought that the increase in free radicals formed from the elevated glucose levels leads to the major problems associated with diabetes (blindness, kidney failure, and CHD).

    When you follow the incidence of obesity and diabetes graphically, you can see that from the start of the 1980s, both here and in the USA, there is a sharp and continuing uptick in incidence of both problems which correlates well with the change in dietary recommendations and the introduction of the food pyramid. The recommendations were to reduce fat intake and increase grain (ie starch) consumption. Now the interesting thing was that there was no science to back up the change and many scientists argued against it, for example, our own Professor John Yudkin and Professor Phillip Handler, a biochemist and at the time President of the American Academy of Sciences. If my memory is correct, the latter testified before Congress and said, in effect, that it was the largest experiment ever conducted on the American population. One only needs to look at our two populations and see that the experiment was a dismal failure.

    Let’s take obesity, if you look even in a first year university text (such as Harper’s Biochemisty), you will see that dietary fat alone does not lead to the secretion of a storage hormone and in fact, fats are readily metabolised for energy by most of our cells, including heart cells. On the other hand, blood glucose rapidly leads to the release of the storage hormone, insulin which tells the fat cells in the adipose tissue to take up fat and just as importantly, it tells the fat cells to retain the fat whilst glucose levels are high. Not only that, insulin also instructs the liver to convert the excess glucose into fat which is then released into the blood stream in the form of vLDLs. These, again under the instruction of insulin, empty their fat content in to the adipose tissue, creating a larger adipose tissue and blood borne LDLs.

    So when you eat/drink sugary/starchy foods for breakfast, elevens, lunch, afternoon tea and then dinner, you are bathing your body in insulin and pushing it into making and storing fat.

    If someone has trouble accepting these concepts – consider:
    1. When you feed geese grain – they convert the starch into fat and develop fatty liver – the delicacy, pate de foie gras;
    2. When you feed very young children a very starchy gruel, as is the custom in some African countries, the children again develop a large belly ie a large fatty liver;
    3. When farmers wish to increase the amount of fat (marbling) in meat, they begin to feed the cattle grains a few weeks before slaughter;
    4. When people develop the autoimmune disease, Type 1 diabetes, the destruction of their pancreatic cells can be so rapid that the production of insulin falls very rapidly and then their adipose tissue simply releases its fat store at such a rate that the body produces so many ketone bodies that the patient dies of ketoacidosis. In other words, as mentioned above, insulin not only controls the uptake of fat into the adipose tissue but also, its release.
    5. We are designed to store food after a meal. The best storage material for an organism like us which required mobility to hunt and avoid predators, is the one that contains the most energy for its weight ie fat (approx. twice the energy of carbohydrate). So whilst waiting for the next meal to walk by, we used our fat reserves as an energy source. These reserves can keep us going for days if necessary – unlike our carb reserves which are depleted in a few hours. In other words, fat is not an alien energy source, in fact most of our cells can use it and many prefer it.

    • Dr Charlie, This is such a lovely clear explanation, thank you. I hope to use it and pass it on. Excellent article, Jerome.

    • mikecawdery says:

      Dr Charlie,

      A man after my own heart but as a vet with decades of experience in among other things, nutrition, what you describe is simply common sense. Unfortunately, medics do very little nutrition (if any) in their seven year training, Top that of with the DIRECTIVES (aka Guidelines to protect the authors) that tells them what they must do and you have the current system that Keys and his flawed studies gave rise to. Dr Yudkin way back in the late ’60s early 70s pointed this out but his views and research were rejected out of hand; though I note that some youngsters are now suggesting sugar is bad as a NEW idea.

      • Leaf Eating Carnivore says:

        It’s all about saving face and money.

        If said youngsters were to realize that this is a very old idea, and said so out loud, they would be pointing accusatory fingers at the old guys who taught them, and who now influence policy and the youngsters’ futures. It’s safer to pretend than to tell the truth – that “Medicine” is as corrupt as Wall Street, rife with politics and greed, legions of good guys notwithstanding. It takes a brave soul to publicly worry more about patient health than one’s wallet and one’s standing.

        I applaud those who do – they have my respect.

    • ” Now the interesting thing was that there was no science to back up the change and many scientists argued against it, … Professor Phillip Handler… testified before Congress and said, in effect, that it was the largest experiment ever conducted on the American population”

      I’m not surprised, but still, it is stunning to see this in black and white.

      But I am flabbergasted to learn that doctors tell diabetic patients to eat carbohydrates. Since I was a kid 50 years ago I’ve been thinking that being diabetic meant not eating carbohydrates and probably injecting insulin. But now doctors tell patients to eat cake and take more insulin?

      Wow. Truly unbelievable.

      • I find much of Allopathic medicine akin to the mechanic who, when asked to fix a warning light, ‘does so’ but cutting the wire which turns on the warning light. We would not accept it for our car but people do for their body. Insanity.

  6. And that’s without considering the cascading side benefits not related to diabetes by minimizing refined carbohydrates. Well written as always Jerome.

  7. Given the finding crisis in the NHS diet should be the first treatment but probably takes up more gp time so drugs, even bad ones ate seen as a quick fix

    • I’m sure you are right but what I would argue that if we are going to get out of the trap of a rising population of older people many of whom have metabolic disorders then relying on drugs to keep them well is not a sensible solution. This is a public health issue and need proper funding. Who today would go back to a privatised water and sewage system?? What’s needed is a political commitment to provide links from GPs to centres that can supply good (ie not “low fat”) information about nutrition and exercise and the facilities for people to put it into practice.

    • Dr David Unwin says:

      Well Barb I agree completely.
      I wonder about the idea of giving all type two patients the chance to see what diet can do for three months BEFORE starting lifelong medication. In practice I find over 90% of patients choose to try diet and delight themselves and me with their achievements.
      While I’m on, is it just me or could you look at a lot of NHS info on diabetes and not realise that sugar isn’t a treat to be had in moderation by folk with diabetes, but a food sourse that is essentially poison to them and so to be totally avoided. I don’t agree with ‘a little of what you fancy…..,’
      We live in a go on ‘treat yourself’ world that I feel does harm.
      Crikey what do I sound like ??
      Dr David Unwin

      • As a parent of a Type1 kid I favour a lower carb diet but it’s nigh on impossible to embark on unless you lie to the Consultant and Dietician, and actually these days you can’t really lie anyway as they see our insulin pump data which includes carbs. Because we have no backing from our team there’s no way I can convince my daughter it’s the right approach either. If she had a nut allergy I could stop feeding her nuts without anyone batting an eyelid; as it is she effectively has a carbohydrate ‘allergy’ but the NHS’s answer is to feed her at least 250g of a macronutrient she can’t process without medicine.

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