Wednesday, 2 September 2015

Epidemic of diabetes threatens to bankrupt the HNS

Bees on an artichoke flower in my vegetable garden

The lives of plants and animals are intriguing, but it is human life that never ceases to provide us with an endless supply of drama and humour. Newspaper headlines are, I think, generally intended to be serious, but the shock factor often becomes ridiculous. Like so many things in life, do not take them too seriously but try to identify the facts behind the scary headlines.

We are told that the number of people in the UK with diabetes has increased by an astounding 60% in ten years. In another twenty years or so we might all have diabetes. If this is true then there must be a very obvious cause. I have previously suggested that the main cause of diabetes is a visit to the doctor.

As usual the message is vicim-blaming. The epidemic is due to us becoming obese (another epidemic) and eating too much sugar. Surely our diet and other aspects of lifestyle cannot have changed so dramatically during such as short time. But obesity, although generally and officially viewed as the sign that the Grim Reaper will shortly visit us, is not the disadvantage made out.

And then there is the warning that this epidemic of diabetes will bring about the bankruptcy of the NHS. What on earth does this mean? Do people actually believe this?

"Bring down the NHS" - how could this possibly happen? How would we possibly replace it? Will we transfer pay for the million people who work in the NHS into welfare unemployment benefits for them? Will the hospitals close down?

First we must ask ourselves, is there really an epidemic of diabetes? Well, we don't know. In fact it is now difficult to know what diabetes is - ask experts to define it! 

Diabetes mellitus (DM) means "plentiful sweet urine". It has been known for a long time, since before chemical testing for glucose, when tasting of the urine was necessary. The WHO gave a clear definition of diabetes in about 1983 and it has never removed this definition. It is "a condition in which a random blood glucose is in excess of 11mmol/l on at least two occasions." 

But there is a continuum of blood glucose, like height or weight, and the problem is to define the cut-off between normal and abnormal (disease state). A cut-off point is decided by a committee (e.g. World Health organisation – WHO) rather than by a bio-scientific marker. In more recent years it has been considered that a cut-off of 11mmol/L is too high and thus too many people with unknown and unexpected diabetes might be missed by medical surveillance. Perhaps a cut-off level of 8.5 mmol/L might be in the public interest, and by applying this the number of people with with diabetes is increased enormously "at a stroke", of the pen of a committee. 

However things have moved on further and now people tell me that they have been diagnosed as having diabetes ("having become a diabetic" to use common but unfortunate language) without any knowledge of blood glucose.

The new measure is not the level of free glucose in the blood, which can vary from minute to minute, but the amount of glucose attached to proteins in the blood, and in particular to haemoglobin. The measure is HbA1c, and it is usually expressed as a percentage  the percentage of haemoglobin in the blood to which glucose is attached. Once again there is no specific demarcation between those with and without diabetes but a continuum, and an arbitrary cut-off is necessary to define the "normal".  

HbA1c has been used for several years as a measure of control of diabetes, but it has now come into use as a method of diagnosis. 

However for the purpose of population screening it is a much more expensive test than measuring glucose. Many responsible for public health suggest that blood glucose is best used for identifying diabetes. Public Health England (PHE) suggests, as quoted in The Guardian (26 August 2015), that 5 million people might have high blood glucose levels. It also suggests that "many of those who become diabetic suffer complications such as blindness and foot amputation". The reality is that "many" is just a tiny proportion, although it is very serious for those afflicted.

There is clearly a great effort being made in the UK, and probably in other countries, to identify as many people as possible with diabetes, with financial rewards for the diagnosing doctors. 

And so a combination of case-finding and redefinition of diabetes to include a much greater proportion of the population has inevitably led to a sudden and great increase in the number of people with diagnosed diabetes - that is, a pseudo-epidemic. It is simply not known whether the true incidence of diabetes is rising.

The reason behind the great effort to identify and treat people with diabetes is to prevent the associated diseases of the circulation. These are:
  • disease of the large arteries (atherosclerosis),  macro-vascular disease. This would lead to heat attack (MI, deaths already reducing dramatically), stroke, and major failure of blood supply to the limbs, possibly resulting in leg amputation;
  • disease of the small arteries, micro-vascular disease. This is more specific for diabetes and it causes damage to the retina (blindness should now be averted by laser therapy), kidney failure (a major problem in ethnic South Asians living in the UK), and damage to the nerves supplying the feet, with subsequent painless ulceration that might result in amputation of a foot or the front part of it.
These micro-vascular diseases occur also in people with Type 1 diabetes and are more closely associated with a high blood glucose. However these conditions affecting only the minority of people diagnosed with Type 2 diabetes.

There are two predictable and significant consequences of the diagnosis of diabetes being applied to an individual. One is worry and the other is an increase personal health insurance premiums. Is early diagnosis by population screening worth-while? 

This was investigated by the UK medical Research Council, in Cambridge. It looked at 15,089 people between the ages of 40 and 69 years, who had a high risk (top 25%) of developing Type 2 diabetes. They were invited to screening and were compared to 4137 people who were not invited. Follow up was for an average of 9.6 years and after this time there was no significant difference in outcome between the two groups.

This lack of benefit of screening has not deterred diabetes evangelism, and indeed population screening continues to expand in a variety of ways. This important research project was effectively a waste of time and it has been ignored (even though it received a prize of the research project of the year).

However the outcome measure in this study was death, and this is easy to measure for a large population sample. If we are concerned about reduction in morbidity (illness) within the population, such as visual deterioration, kidney disease, or foot amputation,  data collection over a period of ten years for almost 20,000 people becomes a very major and a very costly process, unfortunately prohibitively so.

We are therefore dealing with population screening to identify a large number of people with hitherto undiagnosed diabetes knowing that only a very small proportion might benefit, and this precise proportion is not known or predictable. 

We might just remember that Type 1 diabetes is the result of a failure of insulin production by the Islets of Langerhans in the pancreas. Treatment with insulin is essential. A major feature of  Type 2 diabetes is an increased amount of insulin in the blood, but there is resistance to its effect. The nature of insulin resistance is far from fully understood, but it means that insulin production within the body must increase. A high blood sugar will only occur when the limit of insulin production has been reached, in other words a relative rather than absolute deficiency of insulin.

Professor Edwin Gale of Bristol University has suggested that Type 2 diabetes is a disease in search of a definition. He goes on to suggest that the term Type 2 diabetes is not a specific disease as its influence on different people varies greatly. In some it is associated by a number of serious and more specific disease processes, but in others it appears to do no harm. If diabetes is to be defined by blood glucose levels then we would be intellectually more honest if we were to use the term "idiopathic hyperglycaemia", which simply means an elevated blood glucose of unknown cause.

In other words we have a great deal yet to understand about diabetes. Rather than the present overall protocol  approach, further understanding will hopefully lead to a more individualistic approach to people with a high blood sugar.

But what about the economic catastrophe that is predicted? Could diabetes possibly "bankrupt" the NHS? The answer is clearly "No". The UK NHS is strictly cash limited by the government. An increased spending on diabetes will need to be balanced by reduced spending on other aspects of health care, unless the government produces additional funding.

Identifying more people with diabetes does not itself cost any money, apart from to the sufferers who must pay higher insurance premiums and who might experience restrictions on employment. The health costs arise from the regular surveillance of so many people (perhaps 10% of the population) by a doctor, or increasingly by a specialist nurse and a clinical team. The regular assessment includes blood tests, retinal screening, foot inspection, blood pressure control, cholesterol management, pharmaceuticals. These all necessitate recruitment of large numbers of staff, and if part of a national programme these become mandatory. Of course there are continual demands for more staff, especially from pressure groups such as Diabetes UK. 

An increased number of people with diabetes is of great financial benefit to the people who treat diabetes. This is true in a salaried NHS, but even more in a health system in which the physician is paid by item of service. "Patient mongering", increasing the number of patients from previously well population, becomes essential for maintaining and increasing income. As Gale indicates, formal guidelines for the masses is in the financial interests of the providers. We must be careful that health systems are designed for the benefit of the patients rather than for the benefit of the providers of care. 

The management of diabetes is increasingly driven by protocols, rigid guidelines, especially when treatment is nurse-led. This becomes expensive because it is not targeted on those individuals who are at particular risk.

The idea of diabetes detection is that the serious vascular diseases will be reduced by the identification of people with high blood glucose, which would then be followed by intensive and effective treatment. We should expect therefore that if the case-finding is effective, then NHS costs will go down, not up!

It is in the interests of most people that disease incidence should be reduced, and this would include diabetes. Early diagnosis is not prevention. If we wish to reduce the incidence of diabetes and its associations ("complications") then we might try to encourage the consumption of less food. This is generally not a successful venture and it is based on a great oversimplification of body size and shape. An expansion of this subject can be found in the book "Curvology - the origins and power of female body shape" by David Bainbridge.

There is another approach that might be helpful. This is the association between diabetes, obesity and low levels of vitamin D. I will expand on this in a future post.


Simmons RK et al

Screening for type 2 diabetes and population mortality over 10 years (ADDITION- Cambridge): a cluster randomised controlled trial. 
Lancet 2012; 380: 1741-48.

Gale EAM. 

Is Type 2 Diabetes a category error? 
Lancet 2013; 381, 1956-57.

Sunset over Baie de la Somme, France, August 23rd 2015

Sunday, 16 August 2015

Cholesterol is not a poison - official

After more than half a century of us being brainwashed the truth is starting to emerge. Up to now, cholesterol  has been viewed as a poison. It is a chemical that if taken by mouth allegedly causes disease (ill-effects) in all people and it is dose-dependent - the more taken and the higher the blood level, the greater the detrimental effect. The other effect of a chemical is an allergic reaction, which affects few people and is not dose dependent (small amounts can cause big effects). 

We have been told constantly that "Cholesterol is Bad". Where did this misinformation come from? Does it make sense that food that humankind has been eating for centuries or millennia suddenly became responsible for an epidemic of heart disease that emerged in about 1924, reached it peak in about 1970 and which has now declined by more than 95%? 

The diet-cholesterol-heart story has dominated our lives and our eating habits. The food industry has had major problems in respect of milk production in particular. There have been winners - the manufacturers of non-butter spreads and other low cholesterol and low fat foods. There is an obvious need to control obesity but this is about the quantity of food not its constituents.

Fortunately most people seem to have paid little attention to the diet-cholesterol story. I am intrigued to watch and enjoy the cooking programmes on the television, especially BBC Saturday Kitchen on a cold wet winter weekend. There is a major Italian influence, as a result of which the recipes generally include lots of eggs, butter, and double cream, with a generous pinch of salt. Our diet police must have been most unhappy with this programme, but now things have all changed.

A major influence on out diet was the Seven Countries Study, by Ancel Keys. The conclusion was probably written before the study was performed and was independent of the findings. It formed a major basis of the diet-heart-cholesterol hypothesis. Since then many studies have shown an absence of effect of cholesterol and fat on blood cholesterol levels and our health, but much of this evidence has effectively been ignored or suppressed.

A diet study from Canada in the British Medical Journal on August 15th 2015. The conclusion stated: "There was no convincing lack of association between saturated fat intake and CHD [coronary heart disease] mortality." The use of the expression "lack of" is an interesting spin - presenting bad news as somehow good. The statement could and should have read: "There was no convincing association between saturated fat intake and CHD mortality." 

But now the evidence of the failure of the diet-cholesterol-heart hypothesis is overwhelming and it can no longer be suppressed or ignored by the custodians of public diet.

The US Dietary Guidelines Advisory Committee has just released the latest edition of Dietary Guidelines for Americans. The important and surprising messages are :

  • cholesterol is no longer regarded as a "nutrition of concern";
  • there is no limit on fat consumption (apart from controlling weight gain).

And so we can now eat with a clear conscience the foods that we (or at least I) enjoy so much - full English breakfast, Ham and Eggs, Duck breast, Eggs Benedict, Sausage & chips fries, and more. I confess however that I eat these infrequently.

And do not forget that blood level of cholesterol is not a good predictor of heart disease, and above the age of 60 years a high level is a good thing. This information is suppressed but perhaps it will come into the public arena in the way that the misinformation of dietary cholesterol has now emerged.

Wednesday, 5 August 2015

Sir Patrick Leigh Fermor (2)

Sir Patrick Leigh Fermor DSO OBE, 1915-2011

Paddy, as he was known to his friends, was a remarkable character, who turned out to be not only an adventurer and a war hero but also one of the best English travel writers of the 20th century.

During his childhood his parents were in India, where his father was a government geologist. He was cared for by his Nanny, who gave him a great deal of freedom and adventure in a rural environment. The restrictions of life came as a great shock to him when at the age of five he went to boarding school, subsequently to schools for “difficult children”.  

Life throughout his schooling was not happy. He was clearly disruptive, a difficult child. He had no ability for anything mathematical, but he loved history, geography and languages.

When at the age of eighteen, the time came for him to leave school (he was in fact asked or commanded to leave), he decided not to go to university but to walk to Constantinople, Istanbul as it is today. He enrolled himself therefore into the university of life, and what he learned was amazing.

He left London in December 1933, taking the ferry to Hook of Holland, close to Rotterdam. From then on, and initially in heavy snow, he was on his feet and the almost two-year adventure had begun. He kept notes of his journey but it was twenty years later that he wrote his remarkable books about his journey.

The first book is entitled “A Time of Gifts”. It describes his journey from Rotterdam through the Netherlands and into German, along the Rhine, over the great European watershed to the Danube and through Bavaria, Austria, and Czechoslovakia (as it was then) to the Hungarian border. During the journey he learns the languages, the history, and the physical and social geographies of the lands that he crossed.

The second book of the series isBetween the Woods and the Water”. He describes his journey through Hungary and into Romania, describing his meetings with many people from various ethnic groups.

The third book had not been completed at the time of his death, but copious notes were available. The book was finally completed and published in 2013. It is entitled The Broken Road. It continues his journey through Romania and then into Bulgaria. He reached Constantinople but then returned to Greece. 

The book ends with his journey around Mount Athos, visiting many of its ancient monasteries. He decided to stay and to live in his beloved Greece with all its history and traditions.

Patrick Leigh Fermor wrote several other books of his life in Greece, for example “Mani”, about the barely accessible peninsula at the south of the Peloponnese where he made his home.

During the Second World War he fought as a British officer with the Greek resistance. He parachuted into Crete, where he joined the resistance against the Nazi occupation. He and Captain W Stanley Moss, supported by local partisans, captured General Heinrich Kreipe, commander of the Nazi army of occupation. 

They held him for three weeks moving at night to escape intense searches by the German army in Crete. They managed to smuggle him out of Crete to a boat that took him to Egypt. This adventure was described in the book (by Moss) and film "Ill met by Moonlight" (1957).

Leigh Fermor was in a way a sort of James Bond character and he certainly became a great hero among the Greeks.

When he ultimately realised that he was dying he decided to return to England to say “Goodbye” to his friends. He died the day after his arrival in England, at the age of 96.

I would like to give you an extract of his journey after he arrived in Greece, from the third book, “The Broken Road”. The setting is a monastery on Mount Athos, Salonika.

18th February (1935), Esphigmenos. I got up rather earlier than usual today, soon after my morning tea, of which Father Damascene gave me two cups, and putting on my soft Bulgarian moccasins, as it was a glorious, sunny day, prepared to spend the morning up on the hillside. Delving in the bottom of my rucksack for the A Shropshire Lad my mother gave me last birthday, I found an envelope full of Capstan Navy Cut. This was a real find, and getting out my best  pipe (unsmoked for nearly a month) I stuffed it full and set it alight. I’m sure the good God never breathed incense with more delight than I felt then. Pipe tobacco, after a month’s cigarette smoking, is an ecstasy too deep for words.”

The details of his journey are remarkable, but I would like to draw attention to his discovery of a supply of tobacco in his rucksack, and then his thoughts on smoking.

A current Post describes the observation that if you are going to smoke (I emphasise that I do not smoke) then the place to live is Greece.

The sun appears to protect against the damaging effects of smoking. It seemed to work for Patrick Leigh Fermor as he remained active and healthy until his death at the age of 96 years.

Greece - smoking and the sun (2)

At one time life was simple and we knew all the answers. The cause of disease (and everything else) was God, often acting in response to the sins of mankind. The public health officials of the time might have advised “less sin”, but either the population ignored the advice or the concept was flawed.

The most important discovery of the Age of Enlightenment was “ignorance”, the realisation that divine intervention was at the very best unreliable, and probably non-existent. We were therefore ignorant of the causes of disease.

Yuval Noah Harari, in his remarkable book “Sapiens - a brief history of humankind” proposes that the unique attribute of Homo sapiens, the present humankind, is our ability to create abstract ideas, to create fictions. Our many gods are clear examples of this. Fictions are our attempt to explain the world as we experience it. We use fictions to try to make sense of the diseases that afflict us. Often these indicate the blaming of the victims for the errors of their ways, eating the wrong foods, not taking sufficient exercise, or, the greatest sin of all, smoking.

In the absence of divine activity we must search for physical explanations for diseases. We can classify inherited disorders, which can be genetic (from the moment of conception) and congenital (abnormalities of our construction), and both of these in the past have been ascribed to divine retribution for the sins of the parents. Disease acquired after birth can be due to environmental factors, which can be physical (injury, heat, cold), chemical (poisons meaning too much, or deficiencies meaning too little), or biological (a wide variety of micro-organisms).

The elusive nature of “proof” is described and advanced by “Hill’s Criteria”, in an associated Post.

Science starts with observation. We look for clues to give us a way to construct a fiction of causation, called a theory or hypothesis, or a paradigm when it receives general acceptance. But fictions are not absolute truths and fictions change with increasing knowledge.

Causation is complex. For example we have seen that although we accept that cigarettesmoking is the major cause of lung cancer, the fact that only 10% of heavy smokers die from lung cancer indicates that other factors must be considered. These can be viewed as “susceptibility factors”, or perhaps “protective factors”. We can regard disease as the result of interaction between “the cause” together with susceptibility or protective factors, which might be genetic or environmental.

Clues to the identification of susceptibility and protective factors, and indirectly to causation, can be gained from comparing disease incidence in different populations, that is the geography of disease. This is an important dimension of epidemiology. An example is the “Greek paradox”.

I have been warned that data from Greece may not be entirely reliable as it is a country with an unusually well-developed culture of fiction. However WHO data that includes Greece is the best data that we have and we cannot ignore it.

Greece apparently has the highest prevalence of cigarette smoking in Western Europe, as we can see in Table 1. (cigarette smoking has a higher prevalence in the former Soviet countries in Eastern Europe)

Figure 1: percentage of adults who smoke

However Greece has within Europe the lowest age-standardised death rate from coronary heart disease (CHD). The paradox is that cigarette smoking is considered to be a major causative factor of CHD. Where there is a high prevalence of cigarette smoking we expect to find a high death rate from CHD, but not so in Greece. In Table 2 we see age adjusted death rates in men from myocardial infarction (data from WHO 1986).

Figure 2: age standardised death rates from myocardial infarction

Why is it that cigarette smoking in Greece does not cause the high incidence of premature death from CHD that it does in other countries?

“The Seven Countries Study” written Ancel Keys has been the subject of a previous Post. Although methodology was far from perfect and conclusions were not very objective, the study provides a great deal of data. It was very influential in its false conclusion that animal fats cause CHD, and this led to inappropriate diet manipulation over a period of 50 years, continuing to present time.

The study recorded CHD death rates in population samples in some countries within western and central Europe. From the data presented we are able to see that as expected the risk of a man dying from CHD increases with the number of cigarettes smoked. This is obvious if we look at countries in Northern Europe. 

Figure 3: CHD death rates and smoking - northern Europe

The slope of the graph-line rises steeply, indicating that as the number of cigarettes smoked increases, the CHD death rate increases substantially.

However the slope of the graph-line is different in what was then Yugoslavia, mainly Serbia (study population from Belgrade). In this more central country of Europe, the graph-line once again shows an increasing incidence of CHD death with an increasing number of cigarettes smoked, but the graph-line is not as steep.

Figure 4: CHD death rates - northern and central Europe

This indicates that the damaging effects of smoking in Serbia are not as great as in the northern countries.

If we now look at Greece and Italy, countries in the south of Europe we see a graph-line that is almost flat.

Figure 5: CHD death rates and smoking in Europe

This indicates that the risk of CHD death at the age in the study is very low in those who do not smoke, and this is what we expect. However the risk increases only marginally in those who smoke heavily.

What this means is that the risk of a heavy smoker dying from CHD increases dramatically as we move north through Europe. If we look at the low or no cigarette smoking rates in the three European regions we see little difference. If however we look at the heavy smoking group we see a major difference.

It appears to be fairly safe someone in Greece to smoke heavily but it is very dangerous for someone in the northern countries of Europe.

But this feature of Greece and Southern European countries is seen in more diseases than CHD. There is a similar observation of the incidence of breast cancer and colon cancer having a diminishing incidence in the south of Europe compared to the north.

Figure 6: cancer rates and latitude in Europe

The first observation of a latitude effect of cancer incidence was in North America.

Figure 7: Cancer and latitude in Americas

Death rates from cancer increase in the northern parts compared to the southern parts.

The obvious and most simple difference between places closer compared to more distant from the equator is the climate, and in particular the different intensity of the sun.

The observations of cancer death rates and the effect of cigarette smoking on CHD death supports the proposal that exposure to the sun (avoiding severe sunburn) is a great advantage to our health, and reduces the risk of damage from cigarettes.

There is evidence of a help from vitamin D and the sun in thosewho are diagnosed with lung cancer, in an associated Post.

If someone wishes to enjoy good health and a long life but nevertheless wishes to smoke, then it is advisable to live in Greece - see Post Sir Patrick Leigh Fermor (died aged 93).