How To Solve the Diabetes Epidemic
Nearly 21 million Americans are believed to be diabetic, according to the Centers for Disease Control, and 41 million more are prediabetic -- their blood sugar is high and could reach the diabetic level if they do not alter their living habits. Nationwide, the disease's cost for 2002 -- from medical bills to disability payments and lost workdays -- was conservatively estimated by the American Diabetes Association at $132 billion. All cancers, taken together, cost the country about $171 billion a year.
The disease could actually lower the average life expectancy of Americans for the first time in more than a century. According to the CDC, one in three children born in the United States five years ago are expected to become diabetic in their lifetime, and a child found to have Type 2 diabetes at age 10 will see his or her life shortened by 19 years.
''Either we fall apart or we stop this,'' said Dr. Thomas R. Frieden, commissioner of the New York City Department of Health and Mental Hygiene. 'I will go out on a limb,'' he said, ''and say, 20 years from now people will look back and say: 'What were they thinking? They're in the middle of an epidemic and kids are watching 20,000 hours of commercials for junk food.' ''
According to the Office of Minority Health and the American Diabetes Association, the threat of diabetes is related to ethnicity and economic class. African Americans are more than twice as likely to be diagnosed with diabetes as non-Hispanic whites. One in every four African-American women over 55 has diabetes. And African Americans are 2.1 times more likely as non-Hispanic whites to die from diabetes.
Similar trends are true for Hispanics who, on average, are 1.7 times as likely to have diabetes as whites, and for American Indians and Alaska Natives, who are 2.2 times as likely as non-Hispanic whites of similar age to have diabetes.
Type 2 (adult onset) diabetes, which accounts for about 90 percent of all diabetics, is pretty clearly a disease of diet and lifestyle. And that's the good news. According to Neal Barnard, M.D. and founder and president of the Physicians Committee for Responsible Medicine (PCRM), a change in diet can not only prevent the onset of Type 2 diabetes, but can reverse the disease and even get some Type 2 diabetics off insulin.
NEAL BARNARD, M.D., is the author of several books:Eat Right, Live Longer; Food for Life; and his latest, Dr. Neal Barnard's Program for Reversing Diabetes: The Scientifically Proven System for Reversing Diabetes Without Drugs.
Terrence McNally: Is it safe to say that lifestyle, nutrition, and prevention were not the cornerstones of medical education when you were in med school?
Neal Barnard: Well, not only were those things neglected in medical school, they were completely neglected in my personal life. I grew up in Fargo, North Dakota. My grandfather was a cattle rancher. My father grew up on a cattle ranch, and all my uncles and cousins are still in that business. I think I ate roast beef, baked potatoes and corn every day of my life -- except for special occasions, when it was roast beef, baked potatoes and peas.
When I went to medical school, we learned a great deal about how to diagnose conditions, how to manage them medically, and how to prescribe drugs. Unfortunately, one thing we did not pay much attention to was how to prevent conditions like cancer or heart disease. The number one thing when it comes to preventing illness is what we eat. Diet plays a more substantial role than smoking for most major cancers. But with regard to public awareness, even among physicians, with diet we're now where we were in about 1940 with tobacco. People have inklings -- "maybe I should do something..." -- but no one is doing much about it.
When people finally figured out that tobacco caused lung cancer, they got serious and took action -- not only individually but as businesses, as schools, and as a country. I'm optimistic. I think we're on the cusp of making a major diet change.
McNally: John Robbins in Reclaiming Our Health quotes a startling statistic: Medical students were asked how important nutrition was to health, first as they entered medical school and again when they graduated. At graduation, the number who felt it was an important factor had fallen by about half.
Barnard: Not just during medical school but also afterwards. All doctors need to have continuing medical education in order to keep their hospital privileges. It's rather expensive, and regrettably the drug companies have absolutely cornered that market.
I'm not saying that there's not a role for pharmaceuticals. There is. But that should be our alternative medicine. Mainstream medicine should deal with what's causing the illness in the first place. If it's your diet, let's change that. If that is not enough, then let's add medications.
We've got a ways to go, but the Physicians Committee for Responsible Medicine aims to change that emphasis. We advocate for preventive medicine, good nutrition, more sensible and more ethical research. My hope is that we'll be able to change the face of medicine.
McNally: How would you describe prevention?
Barnard: I think of prevention simply as not getting the diseases that would otherwise be in our future. Others get more sophisticated about it, and say there's secondary prevention and tertiary prevention, meaning once you've already got the disease, can we stop recurrence or can we stop the complications of it.
I have an ambitious goal: Let's preserve the very best of health for as long as we can. If you look at kids today, kids 12, 13, 14 years of age, they don't yet have heart disease so far as they're aware. They don't yet have cancer. They don't yet have diabetes in most cases, although some do. If we intervene with their diets now, we can spare them a miserable future. If we fail to do that, we condemn them.
We need to do more than change the face of medicine. We need to change our culture, and we need to change the way our government deals with nutritional issues and prevention. Right now we have a federal government that, on the one hand, says eat more fruits and vegetables and reduce fat in your diet. On the other hand, there are active programs to promote the consumption of meat and dairy products. Subsidies for meat and dairy are dramatically higher than subsidies for fruits and vegetables.
So confronting all those economic pressures that keep cholesterol on our plates, we've got a big challenge in front of us. But I believe we can do it, frankly, for this reason: People know there's a problem and they're sick of it. If you have a family member who's dealing with weight problems or who has diabetes, it's thankless. People have tried all kinds of solutions, they know that we need a bigger picture, and I think that's where we're going.
McNally: The food industry now admits there are problems, but claims it just wants people to make their own choices. They say the answer is public education, so those choices can be informed. Let's be serious. Nutrition education, if it were robust, might be $100 million, while billions are spent on an opposing form of education -- known as commercials.
Barnard: Every day you can flip on the evening news and half the commercials are for snack foods and fast food restaurants. The other half are for medications to undo the effects of our bad diet. That's the culture we're in. Just to make it explicit: This is not entirely the government's fault, though the government I think supports it.
In the early parts of the 20th century people had lung cancer, and it was unclear why. As time went on, people suspected that tobacco may be the reason. The tobacco industry said, "No way. Tobacco's good for you." You can see commercials and advertisements from not that long ago where doctors would say a particular brand of cigarettes was healthy.
Nowadays we have many forms of cancer, we have heart disease, diabetes and hypertension. I am suggesting that these do not occur primarily due to genetics, bad luck or stress. The main contributor to all of these is what we're dosing our bodies with three times a day.
If you look at Asian countries where meat is not the staple of their diet, where their staple is rice, there's very little cancer, very little diabetes. But if they move to Los Angeles or Chicago or Washington DC, stop eating rice and start eating cheeseburgers or fried chicken -- the rate of diabetes goes up 400 percent and cancer rates explode. Or they can stay in Japan and MacDonald's comes to them. An affluent woman in Japan who has Westernized her diet has nine times the breast cancer risk of a poor woman living nearby who has not abandoned rice and vegetables.
If you go back to the Great Depression or before -- and frankly for much of our sojourn on earth -- people couldn't afford to eat meat twice or three times a day. We ate beans and vegetables and fruits and things, much of it coming from our own gardens. Nowadays, for whatever reason, our culture has allowed us to have bacon and eggs for breakfast, baloney sandwiches for lunch, and fried chicken for dinner. And we are paying a terrible price.
McNally: Briefly what's the current state of things with regard to obesity and diabetes? Are things getting better or worse?
Barnard: Things are getting worse. Some recent statistics: in 1994, fewer than 5 percent of the California population had diabetes. Fast-forward ten years, to 2004. We're up to over 7 percent now, and the Centers for Disease Control say one out of every three kids born today will develop diabetes in their lifetime -- one in three.
Diabetes is the leading cause of blindness, a leading cause of amputations, a leading cause of loss of kidney function. It can take 10 years off your life if things don't go well -- which they normally don't. Three quarters of people with this disease die prematurely of a heart attack.
People come into my office with a sack full of medicines. Typically two for diabetes, one for cholesterol, two or three for blood pressure, plus others. It adds up to anywhere from $2,000-$5000 per person. Multiply that by the 20 million or so Americans who've got the disease, and you can see why it's bankrupting us.
McNally: What's the difference between type 1 and type 2 diabetes?
Barnard: In diabetes, the main problem is that there's too much sugar in the blood. Sugar is supposed to get into the cells to power your muscle cells, power your brain cells. Insulin is a hormone made in the pancreas that travels in the bloodstream to the cell's surface. It's like a key that opens up little doors to let the blood sugar inside.
In type 1 diabetes, what used to be called childhood onset, the insulin is not made any more, the pancreatic cells to make it are dead. Some people believe that early exposure to cow's milk proteins triggers an allergic reaction that causes antibodies to be formed that wipe out those cells.
McNally: Only in a small percentage of people?
Barnard: That's a leading theory. Researchers are still trying to tease out the different causes. Viruses may play a role as well. You seem to need a genetic predisposition to it, but the genes aren't determinate. If one identical twin has type 1 diabetes, usually the other one will not. So we're still sorting it out.
Ninety percent of diabetes is type 2, the adult onset form that's on the rise because of diet and lifestyle. These people have insulin in their body, but when the insulin key arrives at the cell and tries to open up the doors, it can't do it. It's as if somebody has gummed up the lock.
McNally: Haven't people used diet for a while? What's radically different about your approach?
Barnard: Anybody who's been on a typical diabetes diet knows it's an exercise in drudgery, and not very effective. The old approach says, "You can't handle sugar." Sugar's building up in the blood, so don't eat sugar and don't eat anything like white bread or potatoes that digests to sugar in the body. With that approach, people on a diabetes diet carefully monitor their carbohydrate intake, counting up carbohydrate grams. In most cases, they need to lose weight, so the diet says go to bed a little hungry to knock 500 calories a day off your diet. By Wednesday that gets very old.
Our muscle cells, however, are powered by sugar and glucose. Marathon runners carbo-load before a race, trying to increase the amount of sugar stored in their muscles and in their liver. But tiny little droplets of fat have accumulated inside the muscle of a person with type 2 diabetes. So insulin arrives in the blood, like a key, it goes into the lock, trying to open up the doors -- but there is so much fat inside the cell that the insulin signaling cannot take place.
We had some insights that allowed us to change the dietary approach to one that is easier and dramatically more effective. It starts with observations. As I mentioned, people on plant-based diets have relatively little diabetes. When they up their fat content they get more diabetes. Vegetarians have much less diabetes compared to meat eaters.
The diet we use says, "Okay, let's not worry so much about carbohydrate, let's take the fat out of your diet." It's not low-carb; it's a vegan diet. Now vegans are not people from the planet Vegas. A vegan diet means no animal products at all -- no chicken, no fish, no dairy, no eggs, and zero animal fat. Step two, keep the oils low. People who take olive oil all over their salad and their pasta, are learning how to use non fat dressings and cooking methods. Step three, we take the sugar out of the diet.
McNally: And you've clinically tested your approach?
Barnard: Our most recent study, starting in 2003 and finishing last year, was funded by the National Institutes of Health and published by the American Diabetes Association. Among those people where everything stayed absolutely constant -- their medicines didn't change, their exercise didn't change -- this new diet was three times more powerful than the current American Diabetes Association diet.
In fact, it was more powerful than any of the oral medicines that people with diabetes use. Individuals with diabetes in our study lost weight dramatically and easily, even though we weren't telling them to count calories. Their cholesterol levels fell, their symptoms improved, they felt better, and many of them got off their medicines or reduced their dosage.
McNally: A positive side effect: The environmental benefits when you stop buying from the poultry and meat industries are phenomenal.
Barnard: When I talk to a lot of younger audiences, they can't picture having diabetes or prostate cancer or arteriosclerosis because they're animal activists or environmentalists.
Americans now eat a million animals per hour -- mostly chickens. Americans now have this tremendous appetite for chicken, naively imagining chicken is somehow a health food, which it's clearly not. Chicken has chicken fat in it. The leanest beef that my Uncle Harold can raise is about 29 percent fat, as a percentage of calories. The leanest chicken, even without the skin, is about 23 percent fat. A bean is about 4 percent.
We have 100 million belching cows on the North American continent. People talk about global warming. There's a lot you can do, but the first thing by all means is retire those cows.
McNally: It's not just the methane they're putting out, it's also the enormous amounts of waste that pollute the water.
So to prevent diabetes, your prescription is stop eating meat and dairy?
Barnard: Avoid animal products completely -- meat, eggs and dairy, even skimmed milk. We are very clear, I can't reverse your diabetes or improve it if you continue to eat poultry and fish.
McNally: But don't we need some of the fats in fish and fish oil?
Barnard: Chinook salmon is about 50 percent fat, and people will say, "It's all good fat." Here's the bad news, I'm going to have to prescribe Prozac to everyone after I tell them this, because they're going to be so depressed. Yes, there are good fats in fish, the omega three fatty acids, for example, which reduce inflammation. But there's also a lot of bad fat in fish. About 15-30 percent of the fat in fish is plain old saturated fat.
McNally: People who avoid all fat miss some elements essential for brain development, etc., don't they? Where does that come from in your diet?
Barnard: There's not a lot of fat in vegetables, beans and fruits, but what there is, is heavily weighted toward omega three. If you want a little extra you can get it from walnut or flax, but I'm not sure anyone really needs that. A man whose grandfather died at age 30 came into our study at 31 when he was diagnosed with diabetes. We didn't tell him to count calories; we didn't tell him to say no to extra portions. He just did vegan, low fat, low sugar. He lost 60 pounds in a year, and in the course of the study his blood sugar values returned absolutely to normal. His doctors stopped all of his diabetes medications. His erectile dysfunction went away. He said, "Why didn't I do this diet 20 years ago?" He never would have had diabetes in all likelihood, had he been on this diet as a child.
McNally: Are people able to comply with this diet? Probably the reason they have diabetes and obesity is because they're eating a fast food diet. When they make that huge switch, how does it go?
Barnard: It goes terrific. Everybody has exactly that question: Can I do it? It sounds extreme, but it's like sticking your toe in a swimming pool. It feels a little cold, but once you jump in, you're going to love it. It beats the socks off continuing to carry that extra weight.
We have some online support for people at the Web site, pcrm.org. We have Q&A and we have a weekly live video conference support group that you can join.
People enjoy it. Start your breakfast with a big bowl of oatmeal. Have a bean burrito instead of that meat taco for lunch. At dinner top your pasta with a marinara sauce instead of the Alfredo. Easy as that and your body starts to heal.