Naysayers, pundits, critics, and cynics are having a veritable love fest this week over the headlines that screamed "NIH stops Look AHEAD trial." The proclamation of "no benefit" from weight loss and lifestyle modification in type 2 diabetes has sent shock waves of disbelief reverberating from living rooms and kitchens to exam rooms throughout America. Rather than advise our patients to just settle into a big cushy arm chair with a bag of Cheetos, I beg of you to at least stick your foot out in front of your metformin-laden Aunt Francis as she makes a mad dash down the sidewalk for the closest Ben & Jerry's. There is much more to this story.
Let's place a Look AHEAD cohort under the microscope. At the beginning of the trial, "Rhonda" weighs 185 pounds and has an HbA1c of 7%. At the end of four years of "dieting and exercising," she still weighs 175 pounds and has an HbA1c of 6.7%. Who in their right mind would think that's really going to make much difference? She's still overweight. She's still diabetic. She's still glycosolating her hemoglobin molecules that were never meant to give sugar a piggyback ride to a retinal or renal arteriole. She looks nothing like the gaunt Paleolithic-appearing Dean Ornish, who hasn't had a gram of fat in 40 years, and she's doesn't look like someone who drank the sugar-free Kool-Aid offered by Atkins. She's probably wearing about the same dress size and looks about like she did when she first started the trial.
Let's face it, 95% of type 2 diabetics--including the typical "Rhonda" patient--could be cured if they achieved a weight that made their neighbors question if they were dying of something. In America, we are not socialized to accept a really healthy weight. Instead, we've been raised on the Hansel-and-Gretel diet, made to clean our plates or our drive-through wrappers until our fat little fingers are just plump enough to appease our penchant for a sedentary lifestyle and distaste for denying ourselves anything. The unpleasant fact is that the typical American smorgasbord has been far more effective than Al Qaeda will ever be in destroying our population. Until we change our trial designs on diabetes and lifestyle and dietary changes, our country will continue to spiral downward into a sinkhole of debt and death. Healthcare reform will mean nothing and healthcare reform will do nothing until we "get it." Our politicians need to leave behind political correctness on this issue because it's lethal.
The Look AHEAD trial looked at how doing very little to affect the disease state we know as adult-onset diabetes can most effectively maim and kill a human organism. As a country, we must unite in an approach that mimics a "12-step program" and do more than just "admit we have a problem." We have to acknowledge that half-heartedly lowering our weight and hemoglobin A1cs are "powerless" over the process. We must come to the understanding that adult-onset diabetes treatment is a commode flush. We either cure it or we suffer the consequences. We either attack it with the same voracity as a sweat-drenched lean GI Jane in Navy SEAL training or go gently into that dark night of complications of stroke, heart attack, limb loss, blindness, and dialysis, and we will swell and pant for air while we are doing it. We have to stop patting our patients on the head and complimenting them on a two-pound weight loss over three months. We must take the office time necessary to explain to them that diastolic dysfunction in the diabetic heart is the Nash equivalent to diabetic liver disease. We must proselytize them with the facts that organs whose fabric is replaced with triglycerides and fat no longer work effectively. Stiff hearts won't drain fluid and blocked arteries can't supply us with blood flow, and worse, plaque rupture kills with stroke and myocardial infarction. We must motivate them and educate them that unless they get busy at curing their diabetes down to a HbA1c of less than 6%, they are not only spinning their wheels, but they may be sliding backward down a very slippery slope to the pit of chronic illness that is costly in terms of human life but also the new human-life equivalent of healthcare dollars.
I insist that the only way to approach the Look AHEAD trial is to take a long look backward at where the "treatment" of diabetes has brought us to this day. After we acknowledge where we have been, then perhaps we can see where we are really going. It's high time to see how doing "something" about type 2 diabetes works, because Look AHEAD has shown us what happens when we do "nothing."
Cite this: The Look AHEAD trial: Much ado about doing nothing - Medscape - Oct 20, 2012.