More and more genetic variants of diabetes such as MODY are being recognised all the time, and these are extremely important, because they open up new possibilities for early diagnosis and treatment. In particular, these advances make it clear that diabetes can no longer simply be divided into Type 1 and Type 2, and that we need to address treatment of the individual patient rather than attempt to force people into diagnostic pidgeonholes that they may not really fit.

TW

Following the recent stopping of the Intensive control arm of the ACCORD study of  patients with Type 2 diabetes because of an excess of deaths in this group, the investigators in the Australian ADVANCE study ran a preliminary analysis of their data, and found no increase in deaths in their Intensive control patients. This will come as a relief to any of you who were worried that tight control might actually be bad for you. There are some differences between the studies - the ADVANCE patients did not already have the same degree of cardiovascular risk factors as those in ACCORD, and the US patients were even more intensively treated with insulin.

So the message as far as I’m concerned still is - go for good control.

TW

Interesting commentary in the Journal of the American Medical Association recently about how abnormal fat metabolism is the root cause of Type 2 diabetes. The author suggests that accumulation of fats in body cells causes insulin resistance and therefore Type 2 diabetes. The fats, he says get deposited in body cells because people eat too much, and he’s probably right, but he doesn’t address the question of what sort of eating too much is particularly bad for you. The current view seems to be that excess calories make you fat, and that since dietary fat contains 9 kcal per gram, this is worse than carbohydrate, which has about 4 kcal per gram, but in fact, what really cause fat to be laid down in cells is insulin, and this is only produced when you take in carbohydrate. So, the theory may be right, but the detail, as always is vital to the message.

 The report is by Unger, JAMA, March 12 2008, Vol 299, No 10, 1185-7.

I just came across a very interesting report in the Journal of the American Medical Association (JAMA) from January this year. This was a controlled trial of surgery (gastric banding) comared with conventional weight loss treatments in obese people with Type 2 diabetes.

The conventionally treated group lost less than 2% of their weight on average, although there was some improvement in their diabetes in those who lost more than 10%. The surgical group lost an average of more than 20% of their weight over the 2 year study period, and a stunning 73% of them had complete remission of their diabetes, with no serious complications of the surgery.

Strong evidence indeed that weight loss is the key to improving control in Type 2 diabetes, although it is disappointing that the results in the diet alone group were so poor and that they lost so little weight. The diet, however, was the usual “balanced” diet still usually recommended by dieticians for wieght loss, and I wonder what would have happenned if a low carbohydrate approach had been used. We can’t use gastric banding on everybody!

The reference is Dixon et al. JAMA Jan 23, 2008. Vol 299 No3. 316-323.