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.

If anyone was getting depressed about the ACCORD results, they can take heart from another large study from Steno in Denmark, just published in the New England Journal of Medicine, in which lowering of the blood sugar and HbA1c levels resulted in an almost 50% fall in overall death rate,  particularly from heart disease.  Many fewer patients progressed to end-stage kidney failure or required laser treatment to their eyes. Major side effects were rare.

You can find the abstract at: http://content.nejm.org/cgi/content/short/358/6/580?query=TOC

Other large studies from both sides of the Atlantic have reported broadly similar results.

We’ll have to wait and see what comes out of the discussion of the ACCORD results, but it is clear that nobody should panic about this or change their treatments right now.

 TW

You will no doubt be seeing in the newspapers in the next few days that one part of the huge ACCORD trial in patients with Type 2 diabetes has been stopped because of an increased death rate in the group of people assigned to intensive blood glucose control. This is a great shock and no doubt will be taken by some people to indicate that good control of blood glucose may be a bad thing.

No single drug or set of drugs could be identified as being responsible for this, but it all the people in this group were receiving multiple treatments for the diabetes and many of them were using insulin as well as tablets. They did seem to have better blood glucose control in that the haemoglobin A1c levels were significantly lower than in the standard treatment group, but despite this more of them died during thestudy period than in the standard treatment group.

As ever, these results need to be viewed with some care. The group of people included in the study not only had had diabetes for an average of 10 years and were relatively old, but they also had poor control and known heart disease or at least two other risk factors. Although their death rate appeared to be higher in the intensive control group, the rate of non-fatal heart attacks was actually lower and there was no consistent cause of the excess of deaths.

Previous studies have suggested that lifestyle measures leading to better blood glucose control can slow the progress of the condition and reverse some of the complications so this result really does come as a surprise.

The first thing to say is that the results may be a statistical anomaly, which are not that uncommon in large trials of this type (remember the HRT trials?). The second is that it is not the lower blood glucose levels that are likely to be causing the deaths, but rather the treatments. Modern views of diabetes care (not yet promoted by either the American Diabetes Association or Diabetes UK) might say that most of the treatments, and particularly insulin in Type 2 diabetes may well cause more problems than they cure.

You will find a good discussion at: http://www.healthcentral.com/diabetes/c/5068/20145/study-whats/1/

If you want to look at the detail and see what the ACCORD study is all about you can find it at http ://www.nhlbi.nih.gov/health/prof/heart/other/accord/index.htm.

In the meanwhile DON’T CHANGE YOUR TREATMENT! Good glucose control matters.

Tony Woolfson