Diabetes is a terrible disease. It consistently ranks in the top 10 causes of death in the United States and causes immeasurable pain and suffering. I started my career as an orthopedic surgeon and foot and ankle specialist and as such have seen first hand the misery in my patients and in their family members. Over 50% of the population is now diabetic or prediabetic so chances are you know someone battling this disease! More concerning than the high frequency of disease is the rate of increase in disease! In 1893 when the first study of frequency in a population was performed the rate of diabetes was 0.3%. In 2002 it was 9.5% and in 2012 it had increased to 14.5%. In fact only 12% of the adult population meets all the criteria to be considered metabolically healthy. Poor metabolic health is increasing at an alarming rate! If you are a diabetic or know someone who is read on because how we as physicians are trained to manage diabetes and how we as a society have come to understand diabetes is fatally flawed.
To understand the failure around diabetes we have to dig a bit into the root of the problem and how it starts in the individual. The big picture is that a diabetic cannot properly handle blood sugar (glucose) in the body and levels of blood sugar can get very high or very low. Both extremes are dangerous for different reasons. There are two types of diabetes, type 1 and type 2. Type 1 diabetes is generally an autoimmune condition that occurs early in life and results in a deficiency of the hormone insulin. Without this hormone the patients cannot metabolize sugar and suffer from very high levels that cause death quickly unless insulin is given. Type 2 diabetes is different. Type 2 diabetes begins with an intolerance to carbohydrates that goes unrecognized for a long time. Many factors play into how this develops but ultimately the hormone levels of insulin, deficient in type 1 diabetics, starts to rise to high levels in type 2 diabetics.
All hormones in the body act as signaling molecules. Hormones rise when needed and fall when not. As diabetes worsens the body requires more of the hormone insulin and levels become chronically elevated. This results in constant signaling that causes the receptor of the hormone to become resistant to the signal which then forces insulin levels even higher. This vicious cycle results in the inability of the cells in the body to properly use glucose as an energy source but also blocks fat cells from releasing fat to be used either. Patients typically gain weight but feel starved because they have no energy and the organ that produces insulin, the pancreas, eventually can’t meet the rising demand and blood sugar levels start to rise. Only after all of this has occurred does a patient get diagnosed with pre-diabetes or diabetes.
Therefore the first failure of our system is that we recognize diabetes as a blood sugar problem. While blood sugar is easy to measure and both high and low levels come with risk there is an insulin problem that precedes the blood sugar abnormality by years! That’s why OHH optimization panels include a fasting insulin level as well as markers of blood sugar so we can identify patients at risk of progressing to diabetes long before they see their blood sugar rise. This is critical because a lot of the harm of diabetes is not due to the blood sugar but due to the chronically elevated insulin levels which go unchecked in our traditional health care system.
The next failure of our system is in the “management” of diabetes. Physicians are taught to educate diabetic patients that they should consume a steady stream of carbohydrates so that the medications can keep their blood sugar levels within the goal range. They should then eat a low fat diet to reduce the risk of heart disease and exercise a certain number of minutes each day. To me and probably most physicians in training this made sense. However, in practice the majority of patients failed to succeed with these recommendations and a well designed 2012 study demonstrates this with less than 1% of patients enrolled in the study using these guidelines stopping progression of their diabetes. Using this approach patients suffer from worsening blood sugar levels and receive increasing doses of medications until they required insulin injections. My diabetic patients told me they felt as though they had failed because their disease was getting worse. In reality, that’s what physicians expect. We are taught that it’s a PROGRESSIVE disease and it will get worse until it or a disease process associated with it kills you. However, I’ve learned since then that this does not have to be the future for diabetics.
So in review, diabetes starts as an insulin problem and the management needs to focus on insulin rather than blood sugar. The current management goals then are a problem. Physicians are trained to slow the progression of diabetes when what we should be trying to do is to put it in “remission.” I use the term remission rather than reversal because someone who has been diabetic will always need to “manage” their disposition but doesn’t need to suffer from the disease. This study utilizing a different approach successfully demonstrated remission of disease in 60% of participants and improvement in medication needs in 94%. That’s markedly better than <1% remission in the study mentioned above. What was their approach? It’s based on what is really causing the problem.
At OHH we work with patients to not only put the brakes on diabetes progression but to actually put it in remission. The secret doesn’t come from a fancy drug or magic supplement, although those can help! The secret is understanding just what diabetes is. It’s an insulin problem with a blood sugar symptom. The secret though goes one step further. The insulin problem comes from misguided nutrition information. Carbohydrate intolerance is the root of probably all type 2 diabetes. There is some nuance to factors that lead to the intolerance but the big picture is that the body responds to carbohydrate consumption with insulin to dispose of the glucose in cells. Excess carbohydrates either from quantity, quality, frequency or all three results in constant exposure of the cells to insulin. This leads to insulin resistance and elevated levels of insulin. Once insulin is elevated the vicious cycle of metabolic disease, prediabetes and diabetes ensues.
Putting diabetes in remission should be our goal. To do that we need to understand that diabetes is a carbohydrate problem, a nutrition and environment problem, not a medical problem. It should be treated primarily with restriction of the source of the problem, carbohydrates. Once that is under control identifying other causes for carbohydrate intolerance can be considered. Consider this in context of any other disease caused by an intolerance or allergy. We don’t tell celiac patients who can’t tolerate gluten to eat just enough of it so they can take a medication to help them tolerate it. We don’t tell an alcoholic to consume just enough alcohol so that we can give them a drug to slow their progression to death. Then why do we tell diabetics to eat “enough” carbohydrates so we can give them medications to keep their blood sugar within range? There is not a minimum required amount of carbohydrate to survive. Everyone should know and eat under their carbohydrate tolerance level. A diabetic will have a lower level than a non diabetic.
When this lifestyle is adapted, medications can be removed, progression of disease halted, weight lost, energy restored and quality of life dramatically improved. If you are or know a diabetic that doesn’t understand this simple truth encourage them to seek a provider that does. Everyone deserves optimal health. Diabetes should not be a common problem. Armed with the correct knowledge and team to help with the right action, diabetes should become a rare phenomenon as it was over century ago.