The Diabetes Industry is Ripe for Disruption

And it has been for some time.

If we plot carbohydrate consumption from low to high on the y-axis, and pharmaceutical—one or more of the many insulins, metformin, etc.–consumption from low to high on the x-axis, we can see all possible combinations of expected patient results on the following matrix:

When exo- or endogenous insulin—and/or insulin sensitivity—is low, and carbohydrate consumption is high, the patient may present with the classical triad of type one diabetes symptoms: polyuria, polydipsia, and  polyphagia: respectively, frequent urination, increased thirst and consequent increased fluid intake, and increased appetite. Other manifestations may include weight loss despite normal or increased eating, irreducible fatigue, and changes in the shape of the lenses of the eyes or sorbitol accumulation, resulting in vision changes.

Patients may also present with diabetic ketoacidosis (DKA), an extreme state of metabolic dysregulation characterized by the smell of acetone on the patient's breath; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and an altered state of consciousness or arousal, such as hostility and mania or, equally, confusion and lethargy. In severe DKA, coma may follow, progressing to death.

Surrounding this cell on the matrix is hyperglycemia, both to the right, when carbohydrates consumed are high and exo- or endogenous insulin is moderate—but not enough to cover the load—and below, when a decrease in carbohydrates is consumed, but still not offset enough by insulin.

In the middle of the chart, where one eats a moderate amount of carbohydrates and injects a moderate amount of bolus insulin, lies the typical diabetes treatment. “Eat a balanced diet and learn to adjust your insulin accordingly” is the principal treatment that is followed here. It is possible to attain near-normal A1c levels with this approach, however, normal weight, blood pressure, not to mention time and resources spent in the process may prove unsustainable. There must be a better way.

Furthermore, this area of the table is fraught with negative consequences at nearly all adjacent and opposite borders. Not enough insulin puts one in hyperglycemia territory both to the left and above. Not enough carbohydrate, and one finds themselves hypoglycemic to the right and below.

At the other extreme, when injected insulin is high, and carbohydrates consumed are too low, severe hypoglycemia could result, necessitating a visit from the local paramedics when subsequent low blood glucose causes unconsciousness. If not attended to quickly, coma and death could occur within minutes.

Too, if carbohydrates and insulin injected are high, the result is a hypo-hyperglycemic swing—a rollercoaster ride if you will—of great magnitude, where the patient is constantly adjusting carbohydrate and insulin loads to offset their blood sugar. 

But look what happens when both carbohydrates and pharmaceuticals consumed are as low as possible. At the far lower-left cell of the matrix, one doesn’t eat a great many non-structural carbohydrates, and, subsequently, does not need to, say, inject much insulin as a result. In this case, one can achieve a normal blood sugar concentration and enjoy the benefits of a normal life, with more energy than previously, stable or decreasing body weight, and less anxiety not having to think about whether one has ingested the correct amount of chemicals. And testing can be reduced to once a day, in the morning, to validate their successful treatment, i.e., whether their morning BG is in the 70-110 mg/dL range. This home base is where thriving begins.

At the zero bolus-insulin and near-zero carbohydrate home, you may thrive for a long, long time. There are three major centenarian studies going on around the world. See the New England Centenarian Study Website, the Georgia Centenarian Study Article, the Georgia Centenarian Study Youtube Video; and the Okinawa Centenarian Study Website. According to Dr. Ron Rosedale back in 1999:

“They are trying to find the variable that would confer longevity among this group of people who live to be 100 years old.  Why do centenarians become centenarians?  Why are they so lucky?  Is it because they have low cholesterol, exercise a lot and live a healthy, clean life?

What researchers are finding from these major centenarian studies is that there is hardly anything in common among these people. They have high cholesterol and low cholesterol, some exercise and some don't, some smoke, some don't. Some are nasty as can be, some nice and calm and some are ornery.  But, they all have relatively low sugar for their age, and they all have low triglycerides for their age. And, they all have relatively low insulin…The way to treat virtually all of the so-called chronic diseases of aging is to treat insulin itself.” See “Insulin and its Metabolic Effects,” by Dr. Ron Rosedale, presented at Designs for Health Institute's BoulderFest, August, 1999. Full online Article.

Although the use of exogenous insulin as a treatment to mitigate the effects of carbohydrate consumption was innovative, exciting, and promising nearly a century ago, its use has become—save on the acutely serious hyperglycemic—grotesquely over-prescribed with the knowledge that carbohydrates are non-essential and that, in the case of T2 diabetics, the problem is initially more of insulin resistance than of insulin production.

For more about the non-essentiality of carbohydrates, see Dr. Eric Westman’s article entitled, “Is dietary carbohydrate essential for human nutrition?” here. For more about insulin resistance, see this full online article.

A remarkable picture develops when you take those three yellow-highlighted cells from the above figure and place them on two different axes, one a continuum of complexity from low to high, and the other, a continuum of knowledge, skills, and tools, again, from low to high.

The y-axis, complexity, relates to the treatment—medication and nutrition—and lifestyle a person implements or recommends. Regarding the x-axis, knowledge, skills, and tools, it could be looked at from two perspectives; one, from a diabetic’s perspective, where the focus is on their knowledge and skills as it relates to implementing advice from a third-party or self-directed behavior, and another, from the perspective of a third-party’s knowledge and skills, be it friend, relative, caregiver, nutritionist, nurse, or doctor. Treatment efficiency and effectiveness in either case is also measured.

The lowest complexity matched with the lowest skill and knowledge will result in a diabetic on the brink. It is quite easy for them to eat carbohydrates at will and develop the hyperglycemic symptoms of full-blown diabetes: polyuria, glycosuria, polydipsia, polyphagia, ketoacidosis, weight loss, etc., culminating in shortened life span. Patient knowledge about diabetes may be non-existent, and they will likely seek out medical attention for help, though, unfortunately, some don’t or for many reasons even if they do, helpful advice is not available. Acquaintances will also most likely notice the change in persona or appearance, and they too will make it a point to tell the person that something is wrong.

“Diabetes Managed” represents a diabetic trying to follow the instructions and advice of his or her general practitioner, though both are influenced by a wide variety of stakeholders with oftentimes divergent self-interests. Influencers in the medical advice providing supply chain may include:

·       Acquaintances, co-workers, family, friends

·       American Diabetes Association (ADA) and other associations/foundations. See especially the ADA’s 2018 Standards of Medical Care in Diabetes.

·       Educators

·       Endocrinologists. See the Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm - 2018 Executive Summary, especially the Disclosures on page 103.

·       Food manufacturers and marketers

·       Medical doctors

·       Medical schools

·       Nurses

·       Nutritionists. Dietetic Associations referred to the public by the USDA include the Academy of Nutrition and Dietetics (FKA the American Dietetic Association), the British Dietetic Association, Dietitians of Canada, Dietitians Association of Australia, the International Confederation of Dietetic Associations, et al. For links see Dietetic Associations.

·       Pharmaceutical companies. See for example Dr. Aseem Malhotra’s appeal to the European Parliament, Brussels, April, 2018. Youtube Video.

·       Popular internet sites, print and TV media

·       Reference media such as the Physician’s Desk Reference, which was formerly a commercially published compilation of manufacturers' prescribing information on prescription drugs, updated annually. While originally designed to provide physicians with the full legally mandated information relevant to writing prescriptions, widely available in libraries and bookstores, widely used by other medical specialists, and in significant part valuable to consumers, it was financially supported in part by pharmaceutical manufacturing corporations which created the drugs listed within its pages. Now it is published only online by ConnectiveRx, and the website is here.

·       Researchers. Most research findings are false for most research designs and for most fields. See Ioannidis JPA. Why Most Published Research Findings Are False. PLoS Medicine. 2005;2(8):e124. doi:10.1371/journal.pmed.0020124. Full online article.

·       United States Department of Agriculture. See USDA Dietary Guidelines.

·       World Health Organization. See their 2016 Global Report on Diabetes.

To the uninitiated, each influencer may seem well-intentioned and sincere; but, by default, advocates of each group act in their own perceived best interests, based upon their knowledge and skill, which may in turn be based upon the state of information available at their time of training or education. Or, they may have conflicting interests, having received benefits from other constituencies. For example, surveys conducted in 2004 and again in 2009 showed that more than three-quarters of doctors had at least one type of financial relationship with a drug or medical device company. (See Campbell EG, Rao SR, DesRoches CM, et al. Physician Professionalism and Changes in Physician-Industry Relationships From 2004 to 2009. Arch Intern Med. 2010;170(20):1820–1826. doi:10.1001/archinternmed.2010.383. Full online article.)

And many of the above influencers have significant power. In fact, some have a near-absolute advantage in the marketplace—the ability to influence behavior without question or pause—leaving the buyer of an optimal diabetes treatment treating their diabetes sub-optimally, i.e., carbohydrate and pharmaceutical intensive. 

And the results? Perhaps an HbA_1c at or below 7%, weight gain, increasing blood pressure, too much time spent counting carbohydrates and measuring insulin doses, anxiety caused by constantly wondering whether or not too much or too little carbohydrates were eaten or insulin dosed, the ever present chance of hypo- or hyper-glycemia, constant blood sugar testing, and the list goes on. “Diabetes Managed” may not achieve optimal results for the patient; but, for other stakeholders, it may bring and keep customers longer.

Although the science behind pharmaceuticals that may limit the amount of glycogen released from the liver or that bind to receptors allowing channel membranes to open so that glucose may cross is remarkable, it is based upon two assumptions: (1) that carbohydrates are an essential majority part of the diet, and/or (2) that through education, a patient cannot, will not, or should not keep from consuming them. Remove those key assumptions, and the house of cards from which that remarkable science is based comes toppling down.

Caveat emptor. “Diabetes Managed” may be the first natural step for diabetics to enter—a complex medical-advice-providing system—in progression of their self-treatment, but it doesn’t have to be.

As knowledge about diabetes and its optimal treatment increases, trusted advisers and patients alike will choose a less-complex method, one that transcends diabetes by avoiding the root cause of symptoms and complications—non-structural carbohydrates—and replacing those carbohydrates in the diet with real food sources of fat and protein, resulting in benefits such as healthy weight loss, normal blood pressure, etc.; in short, leading to a longer, happier, healthier life.

To transcend diabetes requires reduced carbohydrate consumption to near zero, with emphasis on a combination of fats and protein. It is orders of magnitude less complex, less worrisome, and less risky than counting carbohydrates and matching it with doses of insulin or other pharmaceuticals. It is simple. And it should be the first approach in diabetes treatment. See Feinman, Richard, et al. (2014). Dietary carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base. Nutrition. 31. 10.1016/j.nut.2014.06.011. Full online article.

When the blood sugar function is optimized this way, then, a new, refreshing meaning to the words of Frederick G. Banting, largely credited for the idea behind the work which led to the discovery of insulin, becomes evident:

“…with the relief of the symptoms of the disease…the pessimistic, melancholy diabetic becomes optimistic and cheerful.”

This last quote is from the conclusion of Frederick G. Banting, Nobel Lecture, September 15, 1925, The Nobel Prize in Physiology or Medicine 1923. Full online article. That prize for the discovery of insulin was actually divided between Frederick G. Banting and John J. R. Macleod. The choice of this combination of Laureates has been much debated ever since the prize was awarded. Thus, for instance, Banting shared his part of the prize amount with his younger coworker Charles Best. See the article August Krogh and the Nobel Prize to Banting and Macleod.