When Diet Is not Enough

Introduction

In the United Kingdom, as many as one in three type 2 diabetics are managed by diet alone. It's well-known that tight control of blood sugar levels is important for reducing the small blood vessel complications, such as kidney disease, retinal disease, peripheral vascular disease, and diabetic neuropathy. It has been a matter of some anxiety that diet-alone control (i.e. without the use of medication) may not control the blood sugar effectively.

What was done

The National Health Service in the United Kingdom provides centralized medical records for large populations. The investigators examined the records of a quarter of a million patients registered in 42 family practices in the Nottingham area. Patients with diabetes were recognized if they had been diagnosed as diabetic by their family practitioners, or if they had been given one or more prescriptions for anti-diabetic medication. Those diagnosed when younger than 35 and receiving insulin were classified as type 1 diabetics. The remaining (i.e. type 2) patients were grouped into those on medication and those treated by diet alone. An extensive analysis was conducted on the differences between these two groups.

What was found

They were over 7,800 patients with type 2 diabetes. 31% of them were being managed by diet only. However, there was a big difference in this respect in different family practices - it ranged from 16% to 73%.

Compared with patients who were managed with medication, those without medication were more than twice as likely to have HbA1c levels higher than 7.4%. They were much less likely to have documentation of their HbA1c levels, blood pressure, cholesterol levels, or smoking status. Moreover, they were less likely to have urine testing for albumin or foot examinations for possible circulatory disturbances.

On the other hand, those managed by diet alone were more likely to have raised blood pressure (and less likely to be on blood pressure medication), and high cholesterol levels (and less likely to be on lipid-lowering medication).

Diabetic complications were found in 68% of those being treated by diet alone, and in 80% of those on medications. The fact that 60% of those treated by diet alone had vascular complications, 20% had eye disorders, 9% had neuropathy, and 9% had kidney complications was worrying.

What this means

In the United Kingdom there is obviously great room for improvement in the management of type 2 diabetes, if these results are typical. With high blood pressure and raised cholesterol levels as the forerunners of the more serious vascular effects of diabetes (such as coronary heart disease), it seems clear that diet alone is not doing an adequate job.

Diet and exercise alone may be feasible treatment options for some patients who are clearly overweight and eating poorly at the time of diagnosis. However, for the majority of type 2 diabetic patients, some form of antidiabetic medication is going to be necessary.

It is quite probable that such a study conducted in the United States, or almost any other country, would reveal similar problems. The benefits of tight control of blood sugar have been shown over and over again, so that there is no good excuse for physicians to avoid prescribing medication when necessary.