Diabetes
An all too familiar scene in the aftermath of Hurricane Ida. Roof damage from a fallen tree. With a hole in the roof, any time it rains, water gets in the house. You’ll have to deal with puddles on the floor, damaged clothing, electronics, furniture - you name it. Left alone it would lead to mold, mildew, rust, and rot. The longer the water is allowed to sit, the worse the damage. Your solution: mop it up. You’d use towels, mops, buckets, fans - whatever it takes to remove the water.
What happens the next time it rains? Bring out the mops and buckets again of course. It’s not a problem to mop up the moisture whenever it rains. You might not think much of the work and supplies required to clean up the mess. Time and effort are “free”. Mops, towels, laundry, mold mitigation, furniture and clothing replacement aren’t a big deal. Or are they?
What if there were a better solution?
Fix the roof. Treat the root cause. Problem solved.
Diabetics have a “leaky roof”. They don’t process dietary sugar (carbohydrates) normally. When we eat carbohydrates, glucose builds up to potentially toxic levels in the bloodstream. If these levels are high enough for long enough, there can be serious health consequences. For diabetics, the “leak” occurs at least three times a day with carbohydrate rich meals. Potential complications of diabetes include stroke, heart attack, kidney failure, foot ulcers which can result in amputations, blindness, etc. The standard of care in today’s medical system is to medicate the problem. Mop up the leak with pills and injections. Often multiple medications are required to achieve “adequate” blood sugar control. This is not cheap. The American Diabetes Association (ADA) estimates about one of every seven health care dollars is spent on diabetes or its complications adding up to 327 billion dollars in 2017. This represents over $16,000 in annual average medical expenses per patient. https://www.diabetes.org/resources/statistics/cost-diabetes
What if there was a better solution?
Fix the leak. Eliminate the carbohydrates from the diet.
Prediabetes
What if there was a leak in the roof that you didn’t notice? Perhaps it’s a small leak inside a wall and there’s no obvious water. Maybe only a cup or two of water leaks into the wall each time it rains. It may not sound like much, but what if it continues for ten years? There’s a good chance that there will be serious damage over time (rot, mold, etc…) This is similar to pre-diabetes. Blood sugar levels never quite reach the level that would be considered full-blown diabetes. You may never have symptoms, and your doctor would not prescribe medication for pre-diabetes.
The solution is the same.
Fix the leak. Eliminate carbohydrates from the diet.
In medical school we are taught that type II diabetes is a progressive irreversible disease. The goal is to try to keep blood sugar as close to normal as possible with medication. After my research it is unbelievable to me that so little emphasis is placed on lifestyle and nutrition to manage diabetes.
Type I diabetes is caused by essentially no production of insulin by the pancreas (I’ll discuss this elsewhere) whereas type II diabetes is caused by insulin resistance. After you eat carbohydrates, your blood sugar level goes up and your pancreas secretes insulin. Insulin resistance occurs when the tissues of the body become overstuffed with fuel. Your tissues start to ignore the signal from insulin to take up and store this extra glucose. Higher and higher levels of insulin are required to force the various tissues to take up and store the excess glucose. Despite higher insulin levels, the job of clearing the bloodstream of glucose is inadequate, and blood glucose levels rise. This process occurs gradually so that by the time someone is diagnosed with overt diabetes they’ve been insulin resistant for years.
A formal diagnosis of diabetes is somewhat arbitrary. The diagnostic criteria are any of the following:
Fasting blood glucose greater than 126 mg/dl.
Two hour glucose greater than 200 mg/dl after an oral glucose tolerance test (75 gram glucose drink).
Hemoglobin A1c greater than or equal to 6.5%.
Hemoglobin A1c is an interesting molecule. Hemoglobin is the protein in red blood cells responsible for carrying oxygen. A glucose molecule can become attached to this protein (glycosylation) without the action of an enzyme. The percentage of your hemoglobin that has an attached glucose molecule is measured as the A1c value. The percentage of hemoglobin that gets tagged with a glucose molecule depends on the concentration of glucose in the bloodstream. The higher the average glucose, the higher the A1c. Because the lifespan of a red blood cell is about 3 months, the A1c reflects the average blood sugar over the preceding 3 months. A hemoglobin A1c between 5.5 and 6.4 is considered pre-diabetic. 6.5 and greater: diabetic. The treatment goal for diabetics is to achieve a hemoglobin A1c of 7 or less with medication.
Pre-diabetes indicates that you’re “on the train” toward diabetes. Your “check engine” light is on. Typically no medication is prescribed. Without attention, it is likely that pre-diabetes will progress to full-blown diabetes requiring medical therapy. Another variant of pre-diabetes is called metabolic syndrome. This also is a manifestation of insulin resistance. It is defined as a collection of disorders: glucose intolerance (elevated blood sugar), hypertension (high blood pressure), elevated triglycerides, low HDL cholesterol and increased waist circumference. It carries the same implications as pre-diabetes. Don’t take these diagnoses lightly!
Diabetes medications have a variety of mechanisms of action. Some improve insulin sensitivity. Some enhance insulin production in the pancreas. Some cause glucose to be spilled into the urine. Often insulin injections are required because despite chronically elevated insulin levels, even more is required to achieve blood glucose control. A return to the mops, towels and buckets to clean up the mess.
Insulin was discovered in 1921. The treatment of diabetes from medical textbooks before this time was simple: restrict or eliminate carbohydrates. The discovery and isolation of insulin revolutionized diabetes therapy. This was life saving treatment for type I diabetics. Early preparations of insulin were varied in purity and strength making treatment difficult and dangerous. Too much insulin can cause life threatening hypoglycemia (low blood sugar). Because of this potential danger diabetics were encouraged to include carbohydrates in their diet to avoid this complication.
Today, therapeutic carbohydrate restriction is used to reverse type II diabetes. Sara Hallberg has a lovely review from 2019 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520897/pdf/nutrients-11-00766.pdf) which compares very low carbohydrate diets, to calorie restricted diets, to bariatric surgery (gastric sleeve/ bypass). All are effective in reversing type II diabetes. It is my personal opinion that a calorie restricted diet is difficult to maintain in the long term compared to a low carbohydrate diet. While bariatric surgery is effective it certainly seems like an extreme measure to take to achieve the same thing that you can achieve with your grocery basket.
Give it a shot. Fix your leaky roof. Eliminate the carbohydrates. It will change your life for the better.