Yep, this is my problem with all of the focus on “lifestyle” interventions: it’s one step away from blaming the patient for their own disease. With Type 2, in particular, this is never far away. In fact, my doctor told me the day I got diagnosed that it was my fault “for having put on five pounds.” I kid you not.
Glad you figured out that effective treatment is what is most important. Insulin is not a sign of failure, and being able to manage with diet and exercise alone isn’t a sign of virtue, either. As far as I can tell, it’s a combination of genetics and good fortune.
This research showed that people with prediabetes who take part in a structured lifestyle change program can cut their risk of developing type 2 diabetes by 58% (71% for people over 60 years old). This finding was the result of the program helping people lose 5% to 7% of their body weight through healthier eating and 150 minutes of physical activity a week. For a person who weighs 200 pounds, losing 5% to 7% of their body weight means losing just 10 to 14 pounds. It doesn’t take a drastic weight loss to make a big impact.
And the impact of this program can last for years to come. Research has found that even after 10 years, people who completed a diabetes prevention lifestyle change program were one third less likely to develop type 2 diabetes. https://www.cdc.gov/diabetes/prevention/prediabetes-type2/preventing.html
Diabetes incidence in the 10 years since DPP randomi- sation was reduced by 34% (24–42) in the lifestyle group and 18% (7–28) in the metformin group compared with placebo. https://www.ncbi.nlm.nih.gov/pubmed/19878986
The result of over-diagnosing pre-diabetes is that people will be encouraged to lose weight and become more physically active.
The argument against focusing on the pre diabetes group could be that it would be better to spend the resources on broader population-based interventions before pre diabetes develops. These could be making cities more walkable, build bike-lanes, reduce the consumption of sugar and have food policies that promote fruits and vegetable consumption.
I believe we have gone over this before. The work the CDC cites is the 10 year follow up. And you cite relative risk reduction. The 15 year follow up showed that the majority of patients with pre-diabetes went on to develop diabetes after 15 years no matter what they did. The long-term differences become smaller and smaller and after 15 years are almost nil. Yes, doing almost anything can delay the onset of diabetes. But it is delaying. Suggesting that diabetes can truly be “prevented” is actually harmful to patients. Since the majority progress to diabetes no matter what they do this can lead people to feelings of blame and a belief that they should not manage their diabetes because it just doesn’t work.
The argument that Yudkin makes is that overdiagnosing pre-diabetes and treating with metformin has not been shown to change long-term outcomes (as lifestyles has not been shown) and metformin is not without risks and side effects.
I’ve seen people write YDMV a lot around here - we can easily see that we all have different reactions to foods, to exercise, to stress, sleep, colds, etc. I find that the problem with talking about T2 as a class is that “diabetes of unknown cause” really means that there are many possibilities at play. I have PCOS, which is intricately tied to insulin resistance, and ultimately to my diabetes diagnosis. Of course studies must examine classes of people, and we can’t necessarily take into account individuality. Telling people with pre diabetes or T2 that all they have to do is make some lifestyle changes makes blanket assumptions about what my lifestyle must currently be, and does not take into account any other prevalent factors.
Delay does = prevention and it is important to protect beta-cell function as long as possible. Reduction is possible with either metformin or life style. I have pre diabetes and I’m using both methods and look forward to the potential added benefits of heart-health, cancer and Alzheimer’s prevention.
Diet and exercise are not a bad things. Attempting to prevent or delay is important because even if 15 years down the road the results are the same treatment wise there would still be a period when complications have been possibly reduced and damage delayed. How can that not be a win.
Prevention - the keeping of something (such as an illness or injury) from happening.
And I guess in some circumstances you are correct. If you pass away before you get full blown diabetes then you will have prevented full blow diabetes.
I have no issue with lifestyle as an intervention to manage and delay the onset of diabetes. I have a problem with presenting it as a cure or as a prevention.
ps. I’m also not keen on the low fat high carb calorie restricted diet that still pervades the DPP.
“Prevented” means you didn’t get it. “Delayed” means you did. Those aren’t the same thing. I can’t believe we’re consuming oxygen with this rabbinical/jesuitical/lawyer’s semantic game that has little or nothing to do with the topic under discussion—or at least was the discussion started out to be.
I’m actually appreciating the discussion. I think the semantical issue is at the root of why the two camps don’t see eye-to-eye. And that inability to agree is actually precisely why I posted the questions.
Yep, it does bring up some good points. After reading through the admittedly messy conversation, I have some new thoughts on the issue myself. I’m not claiming these are well-thought out, or that I have definitive proof of anything below, but these are my thoughts on the topic now:
Encouraging exercise and eating to maintain a healthy weight is never a bad thing.
The exercise and eating should be society-wide, not targeted to “prediabetics.”
The focus on “prediabetes” and weight, and the inability to differentiate between “delay” and “prevent” likely encourages people that develop Type 2 diabetes to feel like failures. “After all, you could have prevented this with lifestyle changes…”
There has to be a way to encourage people to get healthier without fat-shaming or hanging Type 2 diabetes over their heads as a “punishment” for not having the right lifestyle…
This completely ignores the rather large (although admittedly not a statistical majority) group of diabetics who eat well (high carb, low fat!), exercise, and still get “full blown diabetes” of some type, MODY, MIDD, etc.
There is such a focus on the lifestyle=fat=Type 2 diabetes that people have lost sight of the fact that it requires a genetic predisposition (so far as we know), and that it’s not entirely clear which comes first: an underlying disorder or an inability to control one’s weight.
Sounds like we need social science and medical research to sort out what is undoubtedly becoming an epidemic.
The scientist in me wants to point out that the most significant correlation with developing Type 2 diabetes increases over the last 60 years is the increasing life expectancy. What do all the healthy-weight prediabetics in their 60s and 70s teach us? That they wouldn’t have been prediabetic (or eventually Type 2) if they didn’t have the genes and didn’t grow old… WWII probably helped out the mid-20th C. statistics quite a bit.
Regarding the chicken-vs-egg-who-was-first questions about diabetes, diet, weight, etc. . . . .
Without getting way down into the weeds by attempting the impossible, i.e., condensing a thoroughly researched 350 page treatise down into a sentence or two, it’s worth pointing out that these issues and the latest science concerning them are discussed at length in Gary Taubes’s newest book, The Case Against Sugar. It’s well worth a read. The connection between sugar and tobacco alone will startle you if you weren’t previously aware of it.
That would make auto accidents and suicide alternative “prevention” methods… Sounds a bit too close to euthenasia… I agree with you @Brian_BSC – using words like “prevention” or “cure” automatically places blame on those who don’t…
I am not going to jump into the mix here expect to say one thing I latched on to was that just about everyone who takes the test and is over 65 is going to be flagged as pre-diabetes. And my thinking is by the time you get into your late 60’s early 70’s, is it really going to matter at this point? And please, I know we all want a happy healthy long productive life, but are all these people who end up int the high risk group going to want to change they life they’ve been living for a few more years. Hate to say it, but probably no.
Which is why many medical professionals don’t get those of us who actively manage our diabetes.
That’s a thought that I’ve contemplated as well. I am a 35 year old man, however, and don’t want to speak like I know what a 70 year old is thinking. But I sort of imagine that at a certain point, dramatic lifestyle changes will be difficult…and will the benefit of those changes even “payoff” so to speak?
I just took the test and pretended to be an overweight, active, white, 65 year old woman just to see what it would say, and it came back with low risk. So just age isn’t enough to get you flagged by the test.
I know a number of people (in real life and online) who were diagnosed with pre-diabetes after 55-60 and they decided to make changes, and work on their blood glucose control. Even my mom, who vocally insists that she’s too old at 72 to change who she is or what she likes, takes her medication, makes an effort to get in some regular daily activity, and while she hasn’t drastically changed her diet, she does “watch her sugar” (i.e. limit desserts, not test her blood sugar). Her reasoning is that she doesn’t want to go blind or lose her independence.
So if a doctor (or health organization) is deciding to not tell patients that their blood sugar is starting to go wonky, because they have decided that most people wouldn’t bother, I think that is wrongheaded.
