Wednesday, September 24, 2014

The Nutrition Debate # 247: Age-Based Universal Screening for T2DM


In The Nutrition Debate #244, “Diabetes on Rise but Complications Decline,” I explained what I believe is the primary explanation for the percentage decline in complications from type 2 diabetes mellitus. It is the dramatic increase in the denominator of the fraction, i.e. the number of cases reported, due to changing standards in diagnostic criteria, not that “preventive care for adults with diabetes has improved substantially in recent years,” as the doctors claimed.

 In my opinion, while attention to diabetes – the number diagnosed in particular – has increased, preventive care has not improved. I would make the case that while the number of cases being treated (with better pharmacological agents, I admit) has increased, the medical establishment in general, and the vast majority of individual practitioners in particular, have for the most part ignored the evidence that the best preventative care and the best treatment for type 2 diabetes, is a low-carb diet. In not recognizing that, the medical establishment has been derelict, and I am angry about that.

Now, Medscape.com reports that researchers at Palo Alto Medical Foundation Research Institute, in an online paper in the American Journal of Preventive Medicine, have yet another idea on how yet to identify even more patients with diabetes: screen everyone 35 years old and older for type 2 diabetes. They argue that “guidelines on screening for diabetes are inconsistent with one another and complex for physicians to use.”

For example, “the U. S. Preventive Services Task Force (USPSTF) recommends routine screening of asymptomatic adults only if they have a blood pressure above 135/80 mmHg, while the American Diabetes Association (ADA) recommends screening for asymptomatic adults under 45 with a body mass index (BMI) of 25 or higher and at least one of 12 different diabetes risk factors, and everyone 45 and older regardless of their risk factors.” “It is cumbersome for physicians, and they may not adhere to that guideline,” the lead researcher noted in the Medscape interview.

I was diagnosed a type 2 diabetic in 1986, at age 45. I don’t know the screening criteria my physician used, but I weighed 300 pounds and my blood pressure was 174/124. He started me on micronase, a sulfonylurea, and I’m sure urged me to lose weight. When I moved to NYC, my new doctor, who had a Registered Dietician on staff, added metformin and tirelessly urged me to lose weight (on a balanced, one-size-fits-all, government recommended diet). The diet didn’t work.

Sixteen years after diagnosis, by which time I was maxed out on micronase and metformin and starting a TZD, my doctor read Gary Taubes’s NYT Sunday Magazine cover story, “What If It's All Been a Big Fat Lie,” and tried “the LC diet” himself. It worked. He lost 17 pounds, and his lab tests were stellar. He then suggested I try “the low-carb” (Atkins Induction) too. I did, and over several years, I lost 170 pounds (from a starting point of 375). I still follow it (sort of), and I’ve kept off 125.

Would lowering the screening age (and vastly simplifying the screening criteria to age alone) help to identify more cases of undiagnosed type 2 diabetes? Undoubtedly it would. I was probably a full blown diabetic for years before I was diagnosed. But diagnosis is not prevention or an effective treatment. It would simply lead to earlier treatment, which is good if the treatment works. But if the only arrows in the physician’s quiver are pharmacology, and the one-size-fits-all government recommended “balanced [high-carb] diet,” that will not lead to an effective treatment. It will simply mean that, as the ADA acknowledges, the disease will “progress” (as they admit) and require progressively more medication, as it did for me.

An effective treatment does, however, exist. See “Low-Carb Diet Should Be First Approach for Diabetes.” From the doctor’s perspective, it requires “patient support,” that is, the patient must be willing to do his/her part. But if the patient does, the doctor can just sit back and watch his patient’s health improve. How sweet that was, for both of us. No haranguing or hectoring. Just smiles from doc and a pat on the back. I actually looked forward to my office visits, and I think he did too.

When my doctor started me “cold turkey” on Very Low Carb, he had to take a telephone call from me every day for several days, as I had hypos (symptoms of low blood sugar). He told me to cut back on the meds: eliminate the TZD; then, cut the sulfonylurea and the metformin in half, then cut them in half again. For a year he saw me monthly. He just took blood and did a physical. Eventually, I (we) eliminated the sulfonylurea altogether. Today, I just take 500mg metformin with dinner.
So, my “Practice Pearl” for any physician readers: It is possible – I would say easy – to “cure” your patient of this chronic disease, with “patient support.” And universal age-based screening may be an effective way to identify undiagnosed cases of type 2 diabetes, but preventive care requires an effective treatment. Diet is an effective treatment for type 2 diabetes.

2 comments:

  1. I think what would really help the general population is to make testing for blood sugar as easy as testing blood pressure. You can buy your own blood pressure cuff and do it yourself. When you test at home it takes away the excuses (white coat syndrome, a stressful trip to the doctor, etc). If everyone who was interested in their own health could get their own blood sugar tester, they would discover right away if they actually had a problem and which foods exacerbate that. It shouldn't take a prescription, or even a doctor's recommendation to do this, the monitors should be easy to get and inexpensive. The best I've seen in this department so far are at Walmart. Once I was staying overnight at a family member's house. There were several of us cousins there and I suspected at least 2 of being undiagnosed T2s. When we first got up, even before coffee, I challenged everyone, "I bet my blood sugar is lower than any of yours!" They took the challenge. Mine was 88, the others were all higher, and a couple were above 110, one above 120. They were shocked that a diabetic with toes missing (me) had lower blood sugar than they did. A low carb diet sells itself when a person has the tools to know what's going on with his own body. Doctors really are not needed.

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    1. You're exactly right, Jan. "A low carb diet sells itself..." With your permission, I'd like to use that quote as the title of an upcoming column. Thanks for commenting.

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