The wrong paradigm may be driving drug glucose control in the face of the evidence

Boussageon et al are the latest to highlight the apparent contradiction in our current thinking.¹

On the one hand, the epidemiological evidence shows a strong link between chronic hyperglycaemia (HbA1c) and adverse patient-important outcomes. On the other hand, the evidence from randomised controlled trial shows that lowering HbA1c by drug treatment is ineffective or harmful to patient outcomes.

This contradiction is because we are using the wrong paradigm.

The current paradigm is that HbA1c has a causal relationship with adverse outcomes and that lowering HbA1c by any means must improve patient-important outcomes.

The alternative paradigm is that chronic hyperglycaemia is partly causal, but is only a late and easily measurable part of a more fundamental problem.

Our culturally ‘normal’ diet, based on carbohydrate, is biologically different from the diet the human species evolved to thrive on. A large proportion of people cannot tolerate a carbohydrate-based diet over years, even ‘healthy whole grains’. Eating starch is eating glucose, which requires a corresponding insulin response. An insulin response with every snack and meal for years can, in genetically vulnerable people, cause insulin resistance with variable expression among people and among different body tissues. The Hyperinsulinaemia and Insulin Resistance (HAIR) is the underlying problem driving disorders of glucose and lipid metabolism, characterised by pathological fat deposition as central and visceral obesity, metabolic syndrome, and, when the body’s compensatory mechanisms fail, type 2 diabetes mellitus (T2DM). The whole problem is the cause of the patient-important outcomes, not just the hyperglycaemia.

It is now easy to see: if drugs lower HbA1c by raising insulin and worsening HAIR, this can be ineffective or harmful to patient outcomes.

The standard treatment of T2DM, endorsed by the drug industry, is to base every meal on carbohydrate, which may worsen the underlying insulin response and HAIR, rapidly followed by multiple chronic drug prescriptions, which may be ineffective or harmful even while temporarily improving HbA1c.

A low carbohydrate, high healthy fat ‘real food’ diet can reverse the underlying dietary cause, offload the pressure on glucose and lipid metabolism, and allow the HAIR and T2DM to gradually recover.

• © British Journal of General Practice 2017