Monday, October 21, 2019

Retrospective #247: Age-Based Universal Screening for T2DM

In Retrospective #244, “Diabetes on Rise but Complications Decline,” I explained that the primary reason for the percentage decline in complications from Type 2 diabetes was, due to changing standards in diagnostic criteria, the dramatic increase in the denominator of the fraction from the number of cases reported. It was not that “preventive care for adults with diabetes has improved substantially in recent years,” as the doctors vaingloriously claimed.
In my opinion, while attention to diabetes – and the number diagnosed – has increased, preventive care has not improved. I would make the case that the number of cases being treated (with better drugs, I admit) has increased, but that the medical establishment in general, and the vast majority of clinicians 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 and the clinicians have been derelict, and I am angry about it.
Now, reports that researchers at Palo Alto Medical Foundation Research Institute, in an on-line paper in the American Journal of Preventive Medicine, have yet another idea on how to identify even more patients with diabetes: screen everyone 35 years old and older for Type 2 diabetes. They argued [this was in 2014] 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 in 1987, my new doctor, who had a Registered Dietician (RD) on staff, increased the Micronase ‘til I was maxed out and in 1995 added metformin. He and his RD tirelessly urged me to lose weight (on a balanced, one-size-fits-all, low-fat, high-carb Dietary Guidelines for Americans diet). The diet didn’t work.
Sixteen years after diagnosis, by which time I was maxed out on both 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 recommended diet himself. It worked. He lost 17 pounds. He then suggested I try the very-low-carb diet too. I did, and over several years, I lost 170 pounds (from a starting point of 375). I still follow it, and I’ve kept off 150 pounds.
Would lowering the screening age and simplifying the screening criteria to age alone help to identify more cases of undiagnosed Type 2 diabetes? Undoubtedly. I was probably a full-blown diabetic for years before I was diagnosed. But diagnosis is NOT prevention NOR an effective treatment. It would simply lead to earlier treatment, which is good if the treatment works. But the one-size-fits-all government recommended “balanced [high-carb] diet,” will not work. As the ADA acknowledges, it will simply mean the disease will “progress” AND REQUIRE PROGRESSIVELY MORE MEDs.
An effective treatment does, however, exist. See Retrospective #239, “Low-Carb Diet Should Be First Approach for Diabetes.” But, the patient must be willing to do his/her part. But if the patient does, the doctor can just sit back and watch the patient’s health improve. How sweet that was, for both of us. No haranguing or hectoring. Just smiles from my doc and a pat on the back. I actually looked forward to my office visits, and I think he did too.
So, MY “PRACTICE PEARL” FOR ANY PHYSICIAN READERS: It is possible – I would say easy – to “cure,” i.e. put your patient’s T2DM “in remission,” make your patient’s clinical status “non-diabetic,” and develop a healthy lipid profile, all without or with only minimal drugs. It does, of course, require a willing and motivated patient. Universal age-based screening may be an effective way to identify undiagnosed cases of Type 2 diabetes, or Prediabetes, but preventive CARE requires an effective TREATMENT. A low-carb diet is a very effective treatment for Type 2 diabetes.

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