TYPE II DIABETES ISN'T A DISEASE

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http://www.redflagsweekly.com/kendrick/2003_apr15.html

 

MALCOLM KENDRICK, MD

TYPE II DIABETES ISN'T A DISEASE

 

By Malcolm Kendrick MbChB, MRCGP

malcolm

 

What is a disease? Here are a few definitions, culled from three

dictionaries:

 

a condition of the living animal or plant body or of one of its parts

that impairs normal functioning

 

illness of people, animals, plants, etc., caused by infection or a

failure of health rather than by an accident

 

unhealthy condition of organism or part of organism. 2 (specific)

disorder or illness.

 

Okay, so that counts as pretty unhelpful. A disease is: an illness, an

unhealthy condition, a failure of health, an impairment of normal

functioning. I can sense a circular discussion arriving.

 

There was a time when I thought I knew what a disease was. Then I started

thinking about it, and realized that the concept of disease is horribly

difficult to get a handle on. Superficially, it seems relatively simple to

define disease, and this is probably most true when it comes to an

infectious 'disease'. For here we have an agent, and a set of symptoms and

signs caused by that infection. But even in the case of an infection, what

is the disease? Where is it?

 

If you get infected with the tuberculin bacillus you may develop TB. But TB

can affect the lungs, the gut, the lymph nodes, bone. The infective agent is

the same in each case, but the disease state can vary enormously. Having TB

in the lungs can lead to coughing up blood, breathlessness - death. TB in

the gut can just sit there dormant, unnoticed. Is TB, therefore, always the

same disease, or several different diseases caused by the same agent?

 

Extending this thought slightly, if we couldn't find the infective agent in

TB, would we think that lesions in the gut were the same disease as lesions

in the lungs? I suspect not. We would call TB in the lungs, consumption, and

TB in the guts, bowel nodularity - or something of the sort.

 

What becomes clearer, when you start thinking about things more deeply, is

that, in general, the process of defining disease starts when doctors find

an abnormality. At this point they usually define the abnormality as the

disease, unless, or until, they find a deeper underlying cause for that

abnormality. Thus high blood pressure of unknown cause becomes essential

hypertension, and hypertension is considered by most doctors to be a

disease. Even though there must be a deeper problem that causes the blood

pressure to be high in the first place.

 

Equally, if you find a number of interconnected abnormalities clustered

together, these are quite often named as a disease after the doctor who

first noticed the connections, for example: Parkinson's disease, Addison's

disease, Graves disease, Cushing's disease, Hodgkin's Lymphoma, Fallot's

tetralogy, etc.

 

None of these doctors had the faintest idea what the underlying cause might

be. They just said that they had seen patients with this set of

abnormalities. I hereby name this set of symptoms and signs. Kendrick's'

disease. Well, it has a ring to it. The most recent example I know of is

Gerry Reaven of Stanford University who noticed a number of interconnected

metabolic abnormalities in patients at high risk of CHD. This was called

Reaven's syndrome. A syndrome, not a disease - discuss.

 

So you might ask where has all this has got us.The point I am trying to make

here is that our definition of a disease is actually totally arbitrary. I am

sure that almost everyone believes that they know what a disease is, and

what it is not. But when you try to get a grip on it, you will find the

concept slips away like mercury.

 

Does it matter at all? Is this not just playing with words, asking 'how many

Angels can dance on the head of a pin?' Actually it does matter, rather a

lot. Primarily when we try to treat diseases when we do not know, or haven't

bothered to define, what it is that we are really trying to treat - symptom

or disease; cause or effect. Which, in a roundabout way, is how we get back

to diabetes.

 

Everyone I speak to is certain that diabetes is a disease. But what is

diabetes? The Greek root of " diabetes " means " siphon, " and the Latin root,

" mellitus, " means " honey, " referring to the copious voiding of sweet-tasting

urine by the diabetes sufferer. From the first century a.d. onward, other

emotional descriptions of this killer disease included " sugar sickness, "

" pissing evile, " and " melting down of flesh and limbs into urine. "

 

Actually, that almost certainly wasn't type II diabetes they were talking

about. These were descriptions of type I diabetes. What's the difference?

Type I diabetes happens when the insulin producing cells in the pancreas are

destroyed by an auto-immune process - of unknown origin. With no insulin,

the blood sugar rockets up and sugar starts to leak into the urine. Amongst

other things.

 

Type II diabetes is primarily caused by resistance to the effects of

insulin, or insulin resistance. Usually, there is enough insulin kicking

around, but it doesn't work so well, so the blood sugar level rises. The

different types of diabetes have gone through a number of different naming

protocols. Type I used to be called juvenile diabetes, as it tended to start

at an early age. Type II was called adult diabetes, for obvious reasons.

 

Type I and type II diabetes have also been designated insulin dependent and

non insulin dependent, and type A and type B. There is another terminology

kicking around called Latent Autoimmune Diabetes of Adults (LADA), which

describes adults who end up with auto-immune destruction of insulin

producing cells. There is even another type of diabetes entirely, called

diabetes insipidus. And computer people think it's difficult to keep up with

the speed of change - pah!

 

In this discussion, however, something is already happening that you won't

even have noticed. Something critical. Something that you could stare at for

the rest of your life and never even realize that there was anything wrong

at all.

 

An underlying assumption is now forming in your mind, actually it has

already formed, and it is this. Diabetes is a disease where the blood sugar

level rises too high. (I am restricting the discussion here to type II

diabetes by the way). Of course that is true. Diabetes is a disease where

the blood sugar level rises too high. But what is the disease? The high

blood sugar level? Or the underlying problem that causes the sugar to get

high in the first place.

 

Tracking backwards in time for a moment. When all that doctors were able see

was the passing of 'too much sweet sugar in the urine,' diabetes was called

diabetes mellitus 'passing too much sugary urine.' We know that passing too

much sugar in the urine was a symptom, not a disease, yet we got stuck with

a name that merely described a symptom. We've still got it.

 

Next, it was discovered that in diabetes, the sugar level in the blood was

also very high. So diabetes came to mean a high blood sugar level. It still

does. When Banting Best and Mcleod isolated insulin from the pancreas of

cows and injected it into people with type I diabetes, their blood sugar

level went down, and they recovered. Until the insulin ran out, of course.

 

But it was never the high blood sugar levels that killed a type I diabetic

patient. In diabetes, you die because insulin is required to switch on the

production of sugar receptors from within cells all around the body - other

than in the brain. With no insulin, no sugar receptors are produced, and no

sugar can be absorbed from the blood.

 

With no sugar to use for energy, the cells start to metabolise fat, and

protein. One of the residues of fat and protein metabolism are ketone

bodies, and these are acidic. After a while this 'acidity' cannot be

compensated for, the diabetic falls into an acidic coma and dies.

 

So when Banting and Best gave patients insulin they weren't saving life

because they lowered blood sugar levels, even though they thought they were.

By giving insulin they were allowing cells to manufacture sugar receptors,

absorb and metabolise sugar and clear out the acidity from the blood. The

'disease' they were treating was not a high blood sugar level - it was a

lack of insulin.

 

But because the disease, in diabetes, was a raised blood sugar level, it was

just assumed that it was the lowering of the sugar that was critically

important. And even though everyone now knows that type I diabetics die of

diabetic ketoacidosis, the historical baggage that comes with diabetes has

proven impossible to shift.

 

So we still define diabetes, the disease, as a high blood sugar level. The

current goal of treatment in type II diabetes is to lower the blood sugar

level. But a raised blood sugar level is always a sign of an underlying

'disease, whatever that disease may actually be. Can lowering a metabolic

sign really prevent mortality and morbidity? Are we treating a disease when

we lower blood sugar levels? No, we are not. We are lowering blood sugar

levels which is an effect, not a cause.

 

Does this mean that lowering blood sugar levels is a waste of time.. I

didn't say that, although the evidence that keeping blood sugar levels under

control provides benefit (in type II diabetes) is proving somewhat elusive.

In fact, some studies appear to show that tight blood sugar control may

actually result in increased mortality. This would be surprising if we were

actually treating a disease. But it is less surprising once you recognize

that you are treating a metabolic sign.

 

I will try to finish where I started with the statement that type II

diabetes is not a disease. It can't be because type II diabetes is merely a

blood sugar measurement. A sign, an effect. Not a disease, or a cause. We

have become mesmerized by blood sugar levels - we fight to get them down -

we are happy when the level is lowered. Doctors claim, when the blood sugar

level falls below an arbitrary figure, that the type II diabetes has been

treated, even cured. But what, exactly, have we cured? An annoyingly high

figure on a piece of paper that comes back from the laboratory - or a

disease?