Diabetes develops relatively slowly. You do not
wake up one morning to find that you have got diabetes. For example, it has
been known for many years now that women who are pregnant can develop ‘gestational diabetes.’ That is, a high blood sugar
level that reveals itself during pregnancy, then goes away again after the
diabetes normally returns in any subsequent pregnancy, and goes away again.
Then, some years later, the woman will probably be diagnosed with diabetes. It
appears from this, that pregnancy reveals an underlying progressive problem.
This slow(ish) progression is true of almost
everyone else, and it usually goes through different stages. The first stage,
before there are any symptoms, or any other signs, is an increased insulin
response to a glucose test. A glucose test is where you feed someone a defined
amount of glucose, usually seventy-five grams. This causes the blood glucose to
rise quite rapidly. The sugar level peaks, then falls back to normal within
about two hours. That would be considered normal.
If the insulin level rises higher after a
standard oral glucose tolerance test (OGTT)
this is usually the first sign that diabetes may be on the way. This can
probably best be considered to represent the body trying, and succeeding, in
overcoming resistance to the effects of insulin**. During this stage the blood sugar
levels are normal completely.
Stage two: The insulin level rises
higher, and the blood sugar level rises moderately higher as well. This is
often called an impaired OGTT, or simply IGT (impaired glucose
tolerance). The blood sugar will fall back to ‘normal’ though it may take
longer to do so than in a perfectly healthy person. The fasting blood sugar
will also be normal.
Stage three: The fasting sugar
level is higher than normal. Defined as an impaired
fasting glucose level (IFG). The level will not
be high enough to be called diabetes. In those with IFG
insulin and sugar levels both rise much higher after an OGTT, and take longer
to come back down again.
Stage four: The fasting blood
sugar level is high enough to be called diabetes. The OGTT causes a much higher
‘spike’ in the blood sugar level, and type II diabetes is diagnosed. (At this
point the insulin response to the OGTT may become ‘burnt out’, so the release
of insulin will often be lower than expected).
The length of time it takes to travel from
‘normal’ through stage one to stage four can be decades. It can be much less.
We are now seeing more and more children with stage four (frank diabetes), so
it can obviously develop quite rapidly.
Of course, these stages are somewhat
arbitrary, and the definitions of impaired glucose tolerance moving to impaired fasting
glucose are not fixed. The decision as to when you diagnose diabetes also
depends on specific glucose levels – which have little basis in any solid data.
In fact, as I write, I can guarantee that people will be deciding that the
levels of blood sugar used to define diabetes are too high, and should be
lowered. The sounds of money tinkles gently in background.
There has already been the relatively recent
movement to create the condition known as pre-diabetes.
This means that you are not diabetic yet (using the current figures for
diagnosis), but you soon will be. This process is primarily driven by pharmaceutical companies who are desperate to
‘treat’ ever lower blood sugar levels with life-long medication.
Of course, to an extent, the pharmaceutical companies are right. Why do we only
try to treat people at the point when their blood sugar reaches some arbitrary
point? Surely we should be treating them earlier to stop them reaching this
point in the first place. Well that makes sense…. But only if it works.
Equally, most people with some level of impaired glucose
tolerance usually have other, potentially damaging things, going on. This was
first really highlighted by Gerald Reaven. He
recognised that a number of people who had raised blood sugar levels, but who
were not yet diagnosed with diabetes, had a consistent spectrum of metabolic
and physiological abnormalities. Sometimes called the metabolic syndrome: To quote Wikipedia:
‘The main sign of metabolic
syndrome is central obesity (also known as
visceral, male-pattern or apple-shaped adiposity), overweight with adipose
tissue accumulation particularly around the waist and trunk.
Other signs of metabolic
syndrome include high blood pressure, decreased fasting serum HDL cholesterol,
elevated fasting serum triglyceride level (VLDL
triglyceride), impaired fasting glucose, insulin
resistance, or prediabetes.
Associated conditions include hyperuricemia, fatty liver (especially in concurrent obesity) progressing to nonalcoholic fatty liver disease, polycystic
ovarian syndrome (in women), erectile
dysfunction (in men), and acanthosis nigricans (dark lines on the skin).’
In fact, there are a whole series of other
abnormalities as well. Such as increased blood clotting factors, high levels of
inflammatory markers, high levels of ceremides and diglycerols… the list is
Just to confuse the picture a little more, metabolic syndrome has gone by a number of other
Insulin resistance syndrome
Whatever it was, or is, called, it is clear
that there are stages before frank Type 2 diabetes is diagnosed, where serious
damage is already being done. Various researchers have found that those with
the metabolic syndrome have nearly the same
risk of CVD as people with diabetes.
is a short quote from a paper called ‘Metabolic
syndrome and risk of cardiovascular disease: a meta-analysis.’
‘This analysis strongly suggests that the metabolic syndrome is an important risk factor for
cardiovascular disease incidence and mortality,
as well as all-cause mortality. The detection, prevention, and treatment of the
underlying risk factors of the metabolic
syndrome should become an important approach for the reduction of the cardiovascular disease burden in the general
Perhaps we should rename diabetes completely.
Instead of IGT (impaired
glucose tolerance) IFG
(impaired fasting glucose) and then diabetes. We should call this metabolic condition
stage 1, 2 or 3 diabetes. Maybe I should not suggest this, as the pharmaceutical companies will soon be out with
even more medications, to be used even earlier.
Then we will all be bankrupt.
In fact, at one time there was
an attempt to define metabolic syndrome as a
disease. I am not quite sure how one creates a disease from a syndrome. I think
you just keep saying it often enough until it happens. I presume that the plan
was to find a treatment for metabolic syndrome.
Most people may not have heard of metabolic syndrome, but that is likely to change.
Once known mysteriously as syndrome X, the condition, a precursor to heart
disease and type 2 diabetes, is about to be transformed into a household name
by the US pharmaceutical industry and its
partners in the medical profession. A society dedicated to addressing the
condition has been organised, a journal has been started, and an education
campaign launched. Patients are already being tested for metabolic syndrome. As the trade publication Pharmaceutical Executive said in its January 2004
issue: ‘A new disease is being born.’2
Since then… nothing much has been heard of
this initiative. Why not? Well, if the metabolic
syndrome is the underlying problem in a whole series of other conditions, and
it probably is, then if the metabolic syndrome
went away, all of the associated conditions would simply go away too. No more
high blood pressure, low HDL and high VLDL (dyslipidaemia), obesity,
impaired blood glucose levels fatty liver, erectile dysfunction etc. etc.
Thus, if you actually managed to cure metabolic syndrome, about half the medications prescribed around the globe would no
longer be needed. Tens of millions of people would no longer need high blood
pressure medication. The market for T2DM would shrivel up and die. Pharmaceutical company profits would be
annihilated overnight. So, we hear little about metabolic
However, despite the rapid rise and subsequent
disappearance of the metabolic syndrome, it
does raise a critical issue. Namely that diabetes is far from a simple
condition where the blood sugar level is high – end of. A whole range of other
potentially damaging factors are deranged at the same time. Any, or all of
which could cause the health problems associated with diabetes. Perhaps the
blood sugar level doesn’t really matter at all. It is just a marker for
underlying metabolic dysfunction.
I am not saying that this is necessarily the
case, but the possibility does not even seem to be considered. At present the
very strong impression given, and unconsciously accepted, is that diabetes is
almost entirely about blood sugar levels, and insulin. If the sugar is high,
this is bad. If it is low, this is good. On the other hand, insulin is good, because
it lowers blood sugar levels.
This simple meme was evolved to a large extent
after the discovery of the role of insulin in Type 1 diabetes. Children who have diabetes have a lack of insulin.
If you give them insulin, their sugar levels fall, and they become well again.
Thus it has been accepted that sugar is bad, insulin is good. However, it was
never the high sugar levels that killed them. It was the keto-acidosis caused
by fatty acids escaping from adipose tissue. A
completely different metabolic problem. And, of course, if your blood sugar
level falls too low, this will kill you quicker than anything else. Sugar bad?
Dr Malcolm Kendrick
The Great Cholesterol Con, John Blake Publishing Ltd, 2007
Doctoring Data: How to sort out medical advice
from medical nonsense, Columbus Publishing Ltd, 2014