Type 2 Debate

A recent article (1) brings the current diagnostic and treatment regimens for those who are deemed to be at risk for progressing into Type 2 Diabetes, into question. The arguments are fair and the conflicts are clear. But what the article misses is the risk/return trade-off for the wretched condition. The total cost of diabetes related cost in the US alone is fast approaching $0.5 Trillion. With India and China running fast to the precipice, happily feeding on Western food, we do have a significant issue to deal with.

So, there are two important questions. First, do we have a reasonable idea of the risk of incidence and progression? Age old heuristics such as fasting blood sugar has been shown to be utterly useless. The current golden metric, A1c, is likely equally flawed. The answer to this question appears to be an emphatic no. And second, are the people in charge of prescribing the thresholds for diagnosis and prevention influenced by factors outside science. Unfortunately, the answer to this is likely yes. 

Medicine has always shunned data and analytics in making decisions. This has set them so far behind, the US spends close to 20% of its GDP for worse outcomes. And aging regulators, still using century old statistical measurements to make decisions, makes this worse. The manufacturers, bloated with conventional statisticians, ever ready to prove what the regulators seek, are progressing backward in time. So, it is not surprising that we have ended up in a confusing muddle regarding a disease state that affects close 20% of the world population.

Now, what? It is easy to show statistics that claims only 2% of the pre-diabetics progress into diabetes. Since we are unclear as to the "precise," demarcation between pre and post diabetes, a more relevant question is what the total cost is on the system. A few thousand years ago, humans invented agriculture - and it clearly had an impact on their health. Meat eating humans for millennia, moved to stuff their bodies are not designed to process. In the last hundred years, they had too much to eat and that will certainly create problems not only for their organs, efficiently designed for very little food but also their infrastructure, designed for a slim body. Half the world's population now exceed the parameters of original designs.

Medicine has to embrace modern technology. Doctors should not be simply following rules put down blindly, regulators have to open their windows and realize that the "p-value," is a dead construct and manufacturers need to understand that their job is not a constrained optimization based on what the regulators think.

It is time for the industry to move on.

(1) https://www.sciencemag.org/news/2019/03/war-prediabetes-could-be-boon-pharma-it-good-medicine