TYPE II DIABETES ISN’T A DISEASE

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MALCOLM KENDRICK, MD

 

April 15, 2003

 

TYPE II DIABETES ISN’T A DISEASE

 

By Malcolm Kendrick MbChB, MRCGP (email - 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?

 

 

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