I was a bit taken aback by the title on a recent blog post by Dr. William Davis at his Heart Scan Blog
Why doesn't your doctor try to CURE diabetes?

Dr. Davis paints the medical profession with a rather broad unflattering brush.   Are there docs out there who are more concerned about profit over your health?  Yes.  Are there doctor-drones who reflexively reach for the prescription pad?  Again, yes.   But I believe that most doctors -- and I know several since before they became docs -- do care about their patients and dole out advice based on what they believe to be the best course of action.

Certainly the statement that "Adult diabetes is the one chronic disease that nobody cares to cure" goes more than a bit over the top!

Davis goes on to say that most docs don't think it can be cured, and that is probably true.  The old school re: type 2 would be based on when the disease was more rare and probably not detected until progressed significantly to the point of beta-cell impairment.  But nowadays, with earlier onset and screening, it really can be reversed and "cured" by ..... drum roll please ..... eating less and moving more!  Reducing fat stores below the max fill line (caloric deficit) and exercise work in conjunction to reduce insulin resistance.  I believe successful early intervention can indeed cure the disease.

Dr. Davis goes on to describe a scenario whereby you present at the doctor's office with a FBG of 156 and an HbA1c of 7.1%.  The doc puts you on metformin and the ADA diet.  Now this scenario is presented as if this is some uncaring robo-doc basically going with the flow recommending a course of action with  no track record towards improving patient health.  He also presumes there is no prior treatment history here.  I would venture to guess that most of those who get the diabetes diagnosis from their docs have previously been diagnosed (formally or cautioned) as pre-diabetic and counseled to lose weight .. perhaps on multiple occasions.  IOW, this isn't the first attempt at intervention in the progression of the disease and the patient has failed to make the appropriate lifestyle changes.

OK, so we could argue until we're blue in the face what diet is preferable for weight loss, but there's such a high correlation between obesity and T2 that some have taken to calling it diabesity, and there is ample evidence that just modest weight loss alone can cure it.  LC advocates would blame the doctor for recommending a "failed" low fat diet, but they would be ignoring the fact that many people fail to lose weight on low carb diets as well (and/or fail to maintain it).

If my doctor counsels me to lose weight and I come back 6 months later weighing the same or more, whose fault is that?  The doctor can't hold our hands and can only take our word for it that we tried to lose weight but couldn't or how hard we really tried (vs. compliance was not so hot).    Given the deleterious impacts of glycylation, the doc is doing the responsible thing to lower HbA1C as rapidly as possible with the metformin.  If a patient has not demonstrated an ability to reverse their insulin resistance through lifestyle change, the doc has no choice but to resort to pharmaceutical intervention.

There is emerging evidence that early intervention with metformin is more effective.  In other words, use metformin to attain glycemic control in the early stages and there will be LESS of a need for other medications down the line (or their need will be postponed).  So could it be that the doctors are trying to cure diabetes after all?  Metformin may reverse the condition more rapidly in the short run, and if patients adhere to a reducing diet (even that of the ADA), their diabetes can be cured.  

But Davis will infer no such positive motive on his colleagues.  He presumes that patients will gain 10-15lbs a year on the ADA diet, thereby inferring that in prescribing the diet the doctors intend for their patients to do so.  Huh?!   There are obese/overweight people with serious health issues due to their weight and even those don't "scare them straight" to adhere to a weight loss plan.  I am not condemning or criticizing those people -- I was one although w/o the serious health issues.  But Davis ignores the reality that losing and MAINTAINING weight is both difficult and rare for any number of reasons not related to the composition of one's diet.  The ADA formula of counting calories is a little too low in fat and protein for my tastes, but I hardly see recommending a reducing diet -- any reducing diet -- as irresponsible.  Certainly since weight loss has been shown to reverse (aka "cure") T2, especially if caught early, this advice is what Martha would call a "good thing".

I continue to be concerned over whether LC diets that either do not produce weight loss and/or are not consistently complied with present a significant improvement over a HCLF diet.  BOTH elevated glucose and NEFA/FFA produce deleterious results, and it is the NEFA that contributes to insulin resistance.  LC can lower 24 hr AUC glucose, but if IR persists you haven't "cured" a thing -- only masking a down-line symptom in the progression of a disease.  Metformin, OTOH, increases insulin sensitivity and reduces gluconeogenesis. Perhaps early NEFA lowering pharmaceutical intervention is an avenue to pursue  (metformin's action on lipolysis is inconclusive, it lowers NEFA in some while having no effect in others).

I would agree that all too often patients request a pill and/or doctors reach for the prescription pad to solve medical conditions.  But in progressive lifestyle diseases like this, by the time it gets to the point of diagnosis, lifestyle changes alone may be either too slow or ineffective.  The boat has sailed.  But pharmaceutical intervention need not be for all eternity.  It may well be that just as chemo "cures" cancer by killing off the cells, early intervention to lower circulating glucose and NEFA may well "cure" diabetes provided the IR inducing lifestyle (diet and inactivity) is altered and modest weight loss achieved.

What does it mean to be "cured" of diabetes?  That would be normal basal insulin levels, normal fasting glucose and NEFA's and a normal insulin response to carbohydrate.   If a low carber can't eat a bowl of rice without blood sugar going out of control, I contend their diabetes is not cured but rather controlled.