Thursday, April 19, 2012

Yet More on The Broken Disease Model of Diabetes

In the past I've ranted about how in dustry marketing helped to sell both docs and the general public on a flawed model of what "diabetes" is, for example:

Again with a hat tip to my esteemed colleagues Drs. Rick Bukata and Jerry Hoffman, I was informed of this study by a multi-national team, one of whom is an excellent person, Dr. James Wright at U-British Columbia, whose work on evidence-based prescribing I have long admired:

These folks looked at 13 randomized controlled trials of type 2 diabetes, involving a total of 34,533 patients, which should be reasonably big numbers to be able to draw conclusions. These studies randomly assigned patients to either standard treatment or super-wonderful-tight glucose (sugar) control. According to our preferred model of diabetes, if you can lower the blood sugar, so that nice little machine Wilford Brimley tries to give away on TV will show better numbers, then of course you'll live longer and be healthier.

So what did these studies show? First, overall death rate was no different in tight sugar control vs. less tight control. Second, deaths from cardiovascular causes (mainly heart attack and stroke) were no different in the two groups.

Was anything different? Two things. First, one good thing-- the tight control people did have statistically fewer non-fatal heart attacks--maybe a 15% reduction in the risk of having one of those. Second, the bad thing-- your chance of having a severe episode of low blood sugar, which could lead to seizures or coma, was more than twice as great in the tight control group. For every one person you'd save from having a non-fatal heart attack, you would have about 5 who suffered severe attacks of low blood sugar.

So what's going on here? We have been brainwashed that diabetes treatment is all about controlling blood sugar, which is certainly the case in juvenile onset or type 1 diabetes. In the much more common adult or type 2 diabetes, the evidence is overwhelming that tight control is not the answer, and that our disease model should be all about blood vessel damage prevention and not about tight sugar control. So what does help in diabetes? First, good ol' diet and exercise. Second, quit smoking. Third, control high blood pressure. In short, treat diabetes as a disease in which you need to prevent further vessel damage. (One drug, by the way, is quite good for type 2 diabetes--metformin, a cheap generic, that helps prevent heart disease and also lowers blood sugar, but the two effects seem to be unrelated.)

But you'll never hear that message from drug companies who make drugs that do a wonderful job of lowering blood sugar, but don't do squat to make patients live any longer or healthier. Or from the device and supply companies that make a mint charging Medicare for the test strips that go in that cute little machine.


Steve Lucas said...

This is a topic that seems to be getting a great deal of play at the current time. Having worked for, and around, a number of diabetics I have reservations about the current strategy of tight control, and even some of the self imposed guidelines used by doctors.

An example is a friend of my wife’s who had a series of small strokes. Her recover has been full and everyone is thankful. The problem is she went form zero to an insulin dependent diabetic upon her release and has been put on a diet intended to drop 45 pounds at the rate of two pounds a week. Needless to say her eating restrictions are severe.

So the question becomes: Is the doctor practicing good glucose control or setting this woman up for another health crisis?

I am not a doctor, but experience and logic raises a great many questions about the drive and direction of this person’s care.

Steve Lucas

Joseph Arpaia said...

I have used the analogy of a plane flight with my diabetic patients who were so obsessed with tight control that they were having hypoglycemic episodes.

Fly too high and the plane will struggle, but it will come back down to a safe altitude if simple corrective actions are taken.

Fly too low and flight will end suddenly.