Broadly speaking, diabetes is a disease of civilisation that occurs due to the malappropriation of excessive nutrients in genetically predisposed individuals. This is supported by medical literature showing that type 2 diabetes and other chronic diseases are hardly seen in present day hunting and gathering societies. I understand you are a very busy man and I have no doubt that you are working tirelessly to get Nigeria off the list of polio endemic countries by August 2019. As a Nigerian-trained Physiotherapist, I had so many hours of education in gait analysis and making all kinds of “Plaster of Paris” to correct residual joint deformities associated with poliomyelitis in the late ’80s. Back then polio was a common condition and most of the affected kids were referred to the Physiotherapy Department, often called “komonrin”, which in Yoruba language literally means a place where kids learn how to walk. I must confess that as a physiotherapy student, I hated the fact that all the skills I was acquiring was reduced to mere “Komonrin”.
I am a proud product of Obafemi Awolowo University located in Ile-Ife, an ancient city far less urban than Lagos. While I remember all the cramming I did on diabetes in a class called Medical Conditions Needing Physiotherapy, I still don’t remember seeing a remarkable case of diabetes in the clinical setting, unlike my contemporaries who trained in Ibadan and Lagos. And that brings me to the reason for this letter. I am exactly 25 years removed from direct clinical delivery in Nigerian health services and from a distance, it’s beginning to look like the incidence of diabetes is like the prevalence of polio in my years as a student and professional Physiotherapist in Nigeria.
A national newspaper quoted you in 2017 as saying that Nigeria has 25 per cent of 15 million cases of diabetes in Africa and per your words: “Yearly, there are five million diabetes and diabetes related deaths and every 10 seconds a limb is amputated due to diabetes. In fact, diabetes is now the most common cause of lower extremity amputation. Unfortunately, many of these lives are lost at the peak of their prime in the fifth or sixth decade of lives…” While the epidemic of infectious diseases brings fear and triggers immediate medical emergency response, the same level of urgency is never seen in diabetes because its effects are slow and progressive and could take up to a decade before its co-travelers strike suddenly as heart attacks, strokes, kidney disease, amputation, etc.
As the minister of health of the most populous country in Africa, you have an historic opportunity to lead the world in charting a different path in confronting this global epidemic of diabetes through lifestyle changes to permanently reverse diabetes as against maintaining it.
Sir, I can boldly say that the current sequential addition of multiple medications to aggressively lowering blood glucose is not effective and can be described as “treat to failure”. For instance, before metformin (biguanide) was approved by the Food and Drug Administration (FDA) in 1995, there was just insulin therapy and one class of drug called sulfonylureas. Since then, there have been more than eight classes of anti-diabetes drugs and the incidence of diabetes is far from abating. The projection of a scholarly study published in 1998 stated that “the number of adults with diabetes in the world will rise from 135 million in 1995 to 300 million in the year 2025.” I am writing this early in 2019 and with all the new medications in the market, the prevalence of diabetes in the world is 422 million adults, according to the World Health Organisation (WHO). The U.S.A spends $237 billion directly on anti-diabetes drugs, yet the incidence of diabetesballooned to 30 million in 2018 America. This is in stark contrast to a study published in 2001 stating that “the number of Americans with diagnosed diabetes is projected to increase from 11 million in 2000 to 29 million in 2050”. So much for a $237 billion yearly medication cost!
As a seasoned Obstetrics and Gynaecology consultant, I’m sure you would be pleased to know that your Resident doctor prescribes Panadol to a patient who presents a urinary tract infection, to control the symptoms of high fever. However, you would be shocked if s/he stays on the “sidelines” by continuing to administer Panadol just to control fever without prescribing appropriate antibiotics to address the underlying infection. This hypothetical case sounds ridiculous but sadly that is how diabetes is being medicated with aggressive glucose lowering agents and ignoring the underlying insulin resistance. As stated by Dr. Jason Fung, a Canadian nephrologist with keen interest in diabetes, if a patient started on metformin and ended needing insulin therapy, his blood glucose might be controlled but the diabetes is worsened because his insulin resistance is much higher. It’s like addiction; more is needed to get the same level of kick!
Studies have established that insulin resistance begins with insufficient muscle contractions (i.e. physical inactivity) but the progression to overt diabetes is sustained by insulin resistance in the liver. Insulin resistance in thw liver prompts endogenous fat formation (de novo lipogenesis) and non-stop production of glucose, in addition to the presence of dietary blood glucose. In other words, diabetes presents the double whamming symptoms of too much glucose (glucotoxity) and too much fats (lipotoxicity). While glucose is water soluble and cannot be stored except in small portion in the liver and muscle as glycogen, fats can be stored in the liver and can be exported by the liver to any part of the body except the brain. Increased fat storage in the liver causes increased insulin resistance and excessive fat deposit in the pancreas blocks or impairs the secretion of insulin. Therefore, trying to lower blood glucose does little to the increasingly “fat-soaked” liver and pancreas.
According to a 2018 consensus by American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD), “therapeutic inertia…refers to failure to intensify therapy when treatment targets are not met. Interventions targeting therapeutic inertia have facilitated improved glycemic control and timely insulin intensification.” This is sequential drug addition that has been shown to worsen the insulin resistance! “Insulin intensification” is like the hypothetical Resident stuck on Panadol to treat urinary tract infection. Aggressive glucose lowering with drugs accompanied by insulin intensification boils down to “treat to failure”.
In 2006, Professor Roy Taylor’s study reversed long standing diabetes of up to 10 years by placing the participants in severe calorie restriction of 600 calories a day for eight weeks. Most participants had their blood sugar normalised within seven days and the pancreas began normal insulin secretion in eight weeks. He took MRI of fat content of the liver and pancreas before and after the study and was able to show that fat content was significantly reduced in both organs after the study because severe food restrictions forced the body to “look within” for energy sources.
Without doubt, there are many doctors who are reversing diabetes in a small scale in their individual practices. Most people are also aware of friends or family members who no longer need anti-diabetes drugs after losing significant weight. Morbidly obese diabetic patients who undergo bariatric surgery for gut tightening or partial gut removal often have their blood sugar normalised within days after surgery, even before the obvious loss of weight.
Remission occurs in reverse by intentional calorie restriction and varying forms of fasting to resolve “fat soaked” liver and pancreas. The reversal of permanent diabetes must include regular physical activity which also directly causes fat depletion and increases the whole body insulin sensitivity.
Sir, diabetes is a “dietary disease” fueled by insufficient physical inactivity. Professor Taylor’s work also shows that beta cell failure did not necessarily mean beta cell destruction, as once believed. He showed that beta cells regained their insulin secretory function once the fats are depleted by oxidation in the pancreas. In his private practice, Dr. Fung uses an Intensive Dietary Programme in the form of varying degrees of intermittent fasting and high fat diets, which reduce blood insulin levels.
As the minister of health of the most populous country in Africa, you have an historic opportunity to lead the world in charting a different path in confronting this global epidemic of diabetes through lifestyle changes to permanently reverse diabetes as against maintaining it. As I have indicated, diabetes is initiated with insulin resistance in muscle and sustained with lipotoxicity in the liver and pancreas. Remission occurs in reverse by intentional calorie restriction and varying forms of fasting to resolve “fat soaked” liver and pancreas. The reversal of permanent diabetes must include regular physical activity which also directly causes fat depletion and increases the whole body insulin sensitivity.
Prior civilisations ate when they had food which, by the way, required physical exertions to obtain. Three meals with snacks, while doing desk jobs is peculiar only to the modern civilisation. Patients with diabetes can safely fast and be on exercise program under supervision without risk of hypoglycemia if not on insulin therapy. A lean adult stores up to 130, 000 kilocalories of energy that can power 26 marathons and therefore everyone can afford to fast now and then.
As a developing country that cannot afford these expensive glucose lowering drugs and on course to beat U.S. population in 2050, we have nothing to lose by trying to chart a difference course in permanent diabetes reversal. A talented team of endocrinologists, physiotherapists, exercise physiologists, nurses, dietitians and other professionals can come up with guidelines for lifestyle changes for diabetic reversal. A stitch in time saves nine, as they say.
Thanks for your time and best wishes sir.
Mukaila Kareem, a doctor of physiotherapy and physical activity advocate, writes for the USA and can be reached through firstname.lastname@example.org.