The American healthcare system is openly in crisis. The public feels this and frustrations for many people have reached a boiling point. The crisis has two main drivers, which are closely interrelated.
First, costs associated with healthcare have become unbearable and there is no relief in sight. We’re spending $2 trillion dollars annually on healthcare, good for 17.6 percent of our GDP. That works out to $8,233 dollars for every man, woman, and child in the US, according to a recent report by PBS Newshour. The Organization for Economic Cooperation and Development (OECD) is an international economic group comprised of 34 member nations. Average healthcare spending in these countries is $3,286, so American per capita spending is 250% higher than the average. The next highest countries are Norway and Switzerland at $5,388 and $5,270, respectively.
The second (interrelated) driver is our focus on “managing” disease instead of curing or preventing it. Our current system is designed to become more expensive, not less expensive. At close to a billion dollars to bring a new drug from conception through clinical trials and to market, new drugs are not cheap: and what have we gained? New drugs to treat old problems is an expensive and futile proposition.
Even the new technology is born from a reactive mindset instead of a proactive mindset. PET scans, MRIs, and CAT scans are very expensive and relatively new ways to identify the same problems that have been around for centuries. For example, we can very accurately tell you the dysfunctions occurring in the body as a result of longstanding type 2 diabetes, even down to individual nerves. It does not help you get better in any way but very accurately and expensively tells you what’s wrong.
We treat disease, rarely prevent disease, and almost never reverse disease. Instead of treating diseases, we should be treating predispositions to disease.
Type 2 Diabetes: A Case in Point
This is probably best illustrated with a look at the standard way American doctors treat type 2 diabetes. Let me start this discussion by saying something many mainstream doctors would find befuddling and possibly offensive: type 2 diabetes has nothing to do with the pancreas, and if we were testing properly for diabetes and insulin resistance we would have realized this a long time ago.
Type 2 diabetes—and especially its predecessor, insulin resistance—is a disease of virtually every cell in the body except the pancreas. The failure to make this shift in understanding has resulted in an overly medicated, disease-managed nation, with very few patients experiencing cures.
OK, to be more accurate I should say type 2 diabetes has almost nothing to do with the pancreas. Individual genetic variability in over 70 genes known to affect type 2 diabetes— coupled with environmental, dietary, and lifestyle factors—plays a role in cellular sensitivity to insulin and the progression to type 2 diabetes. In other words, it’s a gene problem and a cell problem, not so much a pancreas problem.
Currently we are not screening properly for diabetes risk because we are not properly screening for insulin resistance. Long before a patient is diagnosed with type 2 diabetes, they suffer from something called insulin resistance. Insulin resistance is an abnormal and undesirable physical state in which the body requires higher levels of circulating insulin than normal in order to control blood sugar. For various reasons the cells in the body become resistant to insulin and the glucose in the blood cannot easily enter the cells.
The pancreas responds by secreting more insulin to overcome the resistance. This serves as a compensatory response and works for a long time, sometimes twenty years or more. However, it is a progressive dysfunction and over time more and more insulin is required to keep blood sugar at normal values. To give you an idea, the normal fasting insulin level should be around 10 or less and a fasting blood sugar ideally should be in the 60-90 range.
Testing, testing
For some reason, the convention is to check a fasting blood sugar but not a fasting insulin level. This is absolutely inappropriate. Not only should we be checking fasting blood sugar and insulin level, we should be doing glucose tolerance tests that are five hours long instead of three hours, and we should check both blood sugar and insulin at every blood draw. Only with both of these values can we meaningfully understand what is happening with the patient and understand how best to advise them. If we do not check insulin levels at the same time as blood sugar levels, we will never properly understand the stage of dysfunction present. It will be difficult to properly educate and advise our patients on the best treatment approach. Even worse, if we do not check insulin levels we run the risk of missing insulin resistance altogether.
Such would have been the case with my patient John B. He already had a three-hour glucose tolerance test, (GTT) done by his primary physician as a screening test for diabetes and was told he was fine—all the blood sugar levels were normal. He was very tired and frustrated that he couldn’t lose weight. Even though he ate a lot, he still had food cravings and felt his blood sugar was often low. I told him I wanted to repeat his blood sugar test over a five-hour period and check insulin levels. I was surprised by the results. His blood sugar levels were all perfectly normal except his four hour blood sugar level was slightly low. It corrected at the five-hour check.
When I looked at insulin levels, however, I was shocked. His fasting insulin was not 10, but 272. His one-hour insulin should have been 112 at the highest—it was 462. It never dropped below 100 until the fourth hour when his blood sugar suddenly dropped slightly below normal. Only then did his pancreas slow down the insulin secretion, and it was still above normal.
At this point his liver manufactured the necessary glucose he needed to keep his blood sugar from dropping further via a process called gluconeogenesis.
Simply put, he was severely insulin resistant. He was secreting up to 20 times the normal amount of insulin just to keep his blood sugar normal. He was at risk of becoming diabetic. How much longer could his pancreas keep up that level of insulin production?
Was his problem his pancreas? Absolutely not. His pancreas was doing its job remarkably well: in fact it was doing more than its job, at least four times more! His problem was every cell in the body except the pancreas. His cells were resistant to insulin. By checking blood sugar only, instead of blood sugar and insulin levels, we will fail to diagnose insulin resistance, a reversible abnormal physiologic process that can lead to diabetes.
Over the years as the cells become more and more resistant to insulin, the pancreas compensates by producing more and more insulin. This rising insulin goes unnoticed and gets progressively worse, until finally the pancreas can no longer produce enough insulin to keep blood sugars in the normal range. Only then do we see blood sugars rise: only then do we intervene and say “Aha, I have discovered that you have diabetes.”
What is equally accurate but much less attractive would be to say, “Aha, I have missed and ignored insulin resistance, a progressive, reversible physiologic condition, for the past 10 to 20 years. As a result, I have to treat you for diabetes.” We missed the opportunity to prevent diabetes: what’s worse is that, once diagnosed, we largely overlook the possibility of reversing the disease. Mainstream medicine thinks of type 2 diabetes as a pancreas problem instead of a cell problem. Therefore, they entirely (and I think unknowingly) bypass the cure and go straight to treatment. This is expensive, unrewarding, and, in some respects, futile.
Treating the cells is where the cure lies and is where we should focus our attention clinically. Researchers have already identified 70 or so genes that influence our susceptibility to type 2 diabetes. As we learn more about the influences of nutritional support on gene expression, we may develop new preventive strategies and treatment approaches that help reverse the condition, not just treat it. The treatment approach should be to make the cells more responsive to insulin so the pancreas doesn’t have to secrete as much. There are a few medications that do improve cellular sensitivity to insulin.
Another consequence of insulin resistance is difficultly losing weight and the ability to easily gain weight. Type 2 diabetes is almost always associated with obesity, though there are exceptions. Why is it so hard for people with insulin resistance or type 2 diabetes to lose weight? It is because insulin is a fat-storing hormone. The excess insulin secreted tells their body to store more of what they eat as fat, meaning they do not get the energy that they should from a meal. So they eat again to get the energy they should have received from the last meal. Because of the ongoing excess insulin secretion, they store more of each meal as fat, and on and on.
This is a negative cycle that results in people really struggling to lose weight on very restricted caloric intake and even gaining weight on an otherwise reasonable diet. This is terribly unfair. The patient and their doctor are too often unaware of this metabolic condition.
How can you give good advice to a patient about something you don’t know exists? You can’t.
Treating Insulin Resistance Before It Becomes Diabetes
I have had the good fortune of treating insulin resistance in many patients and seeing the blood tests normalize. Interestingly, it does not usually require any medication.
What it does require is rather specific nutritional intervention that directly targets the cellular response to secreted insulin. It also requires very specific physical activity, including mild resistance training and elevated heart rate training. It is critically important to control the protein-tocarbohydrate ratio in the first meal of the day. In my experience, the higher the protein content of the first meal the better—I usually recommend 50 percent protein or more.
In traditional medicine where we generally check blood sugar levels instead of insulin levels, we miss the opportunity to diagnose insulin resistance or “prediabetes.” If there are 30 million diabetics, there are probably 100 million insulin-resistant or prediabetic cases.
Picking Low-Hanging Fruit
Normal glucose metabolism is critical to maintaining a healthy weight, vibrant energy, mood stability, good concentration, vision, exercise tolerance, normal cognitive function, memory, heart, kidney, and lung function, and essentially every other bodily function. Consequences of abnormal glucose metabolism include dysfunction in all of the above areas and long-term vascular consequences leading to premature heart disease, blindness, kidney failure, impotence, and dementia, to name a few.
We are failing as a profession to prevent and reverse one of the most common and expensive diseases that faces us today. The long-term complications from diabetes are almost too numerous to count and arriving at an accurate estimate of the cost to the healthcare system and the economy is difficult, to say the least. It is safe to say that it is in the hundreds of billions of dollars.
One of the major problems with the healthcare system today is exemplified by the way we approach type 2 diabetes. It starts with the way we train doctors to think. Or, more accurately, the way we train doctors not to think. We systematically train away the natural tendency to be creative, imaginative, and thoughtful when we teach the paradigms, protocols, and algorithms that constitute today’s standards of care.
Reexamining The Standard of Care
For those unfamiliar with the term, the standard of care is something all physicians are taught. It means that for any given disease presentation you do the same thing, every time, for everyone—if not, you risk violating the “standard of care.”
The way the system is set up, violation of the standard of care increases the risk of medical sanctions, loss of medical license, and the likelihood that a malpractice suit will be successful. So we encourage all doctors to treat all patients essentially the same, never mind the fact that no two people are exactly alike and no two presentations of a disease are necessarily alike. Each person is unique, with individual characteristics, strengths, weaknesses, tendencies, genetic predispositions, and environmental exposures, all of which impact the presentation of the disease in unpredictable and unique ways.
We need to treat our patients as individuals, with all of the unique characteristics that make them who they are. We need to understand as much context as we can about the onset and presentation of a disease if we are to give the most meaningful and helpful treatment recommendations.
And even more important is trying to understand the “why” behind it: why did he/she develop this disease? What were the predisposing circumstances that lead to the onset of the disease? If we can understand predisposing factors and target them in a reverse fashion, we can reverse a disease instead of just managing symptoms.
What about treating predisposing factors to disease even after the disease occurs? It may sound counterintuitive or too late, but it’s not. Treat risk factors (or predisposing factors) and you may end up reversing the disease. This shift of focus in treatment approach should improve patient outcomes, patient satisfaction, and doctor satisfaction. It will also help stabilize the ever mounting healthcare crisis, both in terms of expense and outcome.
It’s time to re-examine the status quo and change where we can and where we should. We should be moving to a new era of individualized medicine whereby all of the patient’s individual characteristics and all available context is analyzed in a unique but logical way. The resulting treatment plan may differ from the “accepted standard of care” but may be the most appropriate and efficacious treatment for that patient. To me this is a logical progression and evolution of our healthcare system, but not one that is currently taught. We should promote an environment in which a physician has the opportunity to use their experience, knowledge, creativity, logic, training, and medical understanding to treat and then reverse the problem in front of them, rather than having everyone follow the same standard of care for every patient every time. That takes the art out of medicine and the individual out of the equation.
Who is going to lead us out of the current flawed treatment paradigm into the new era of prevention, disease reversal, and individualized medicine?
Jeffrey Hendricks, MD, has practiced emergency, occupational, family, alternative, and integrative medicine. He has served as medical director for Shoreline Occupational Medicine, Bosch Automotive Corp, Shoreline Alternative and Integrative Medicine, and Biogenesis Medical and Wellness Centers. He is a triathlete, inventor of RIZE health drink, and CEO of Nothing Ventured, LLC.
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