Intended for healthcare professionals

Views & Reviews From the Frontline

A golden syrup

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a510 (Published 26 June 2008) Cite this as: BMJ 2008;336:1508
  1. Des Spence
  1. destwo{at}yahoo.co.uk

Much of my working life is spent listening to confessions. For example, someone with diabetes might say, “I have the occasional KitKat; I’m so sorry, doctor.” Medicine’s denunciation of paternalism is but a sham, for we now attempt to micro-manage every detail of patients’ lives, through medications and health promotion diktats. But this clearly isn’t working.

People with type 2 diabetes fare the worst. Their diagnosis is now an absolute. The term “mild diabetes” has long been retired to the graveyard of defunct terminology, along with “nervous disability” and “rodent ulcer.” Also, we have lowered the threshold for diagnosis, and the meaningless term “prediabetes” stalks some 54 million people in the United States. Diabetes is now a big problem—but an even bigger business.

Then start the horror stories of blindness, dialysis, amputations, and heart attacks—terror tactics used in the name of compliance. Next come the medications—statins, aspirin, and ACE inhibitors, just for a start. Implausible and impossible blood pressure targets lead to multiple antihypertensives, and patients are soon on the full house of poisonous polypharmacy. But lowering glycated haemoglogin (HbA1c) is considered the key, with initial combinations of oral antiglycaemics and now with the widespread use of insulin. All are based on the observational data of the United Kingdom prospective diabetes study and the belief that lowering HbA1c reduces complications.

But two recent prospective interventional studies on tight glycaemic control—ACCORD (N Engl J Med 2008;358:2545-59) and ADVANCE (N Engl J Med 2008;358:2560-72)—challenge this faith system. Not only did lower HbA1c not statistically reduce cardiovascular complications, but it increased all cause mortality. How could this possibly be? In medicine we measure what is measurable—and this makes us blind to the many immeasurable unknowns that confound even the most obvious of associations. Mere association is not causation, so high blood sugar may merely be a symptom of yet undiscovered metabolic pathways.

Have we been wasting our time? Type 2 diabetes is an illness of affluence, a disease of convenience, not a medical epidemic. In attempting to micro-manage the detail we have lost sight of the obvious. Tackling obesity and type 2 diabetes is a macro-management and public health problem. Until there is a political will to make unpopular decisions to build an infrastructure that compels people to be more active and gives incentives for better diets, I fear more time will be spent in the health promotion confessional.

View Abstract