Diet and Exercise Trump Diabetes Drugs

A news search on the word "Avandia," the diabetes drug, will pull up thousands of results, nearly all pertaining to the Food and Drug Administration's decision last week to keep this dangerous drug on the market, albeit with restrictions.

Another search on "Avandia + diet," will produce only a few results. And herein lies the problem. Too many doctors rely solely on prescription drugs to treat their patients' diabetes; and too many FDA regulators leave the concept of diet completely out of the diabetes equation.

Diet-plus-exercise has always been the best method to prevent diabetes as well as to control and even reverse the course of the disease. A study released today in the Archives of Internal Medicine is the latest to demonstrate this.

Real lifestyle change

The study, called Look AHEAD (Action for HEAlth in Diabetes), showed how lifestyle changes help individuals with type 2 diabetes lose weight, control blood sugar levels and reduce risk factors for heart disease.

The lifestyle change did not entail pouring a glass of water, popping the Avandia pill (banned in Europe), and getting on with business as usual. The change was more rigorous: consuming fewer than 1,800 calories daily through portion-controlled meals, and exercising for about 30 minutes a day.

This routine led to significant weight loss — more than 6 percent of original weight over four years on average for the 2,570 overweight and obese patients enrolled in this part of the study — as well as lower blood pressure and higher levels of "good" HDL cholesterol.

Avandia, on the other hand, has led to heart failure. A 2007 analysis in the New England Journal of Medicine found that Avandia raised the risk of a heart attack by nearly 50 percent and the risk of dying from heart failure by nearly 65 percent.

Heart failure is the major cause of death for diabetics. You kind of want a diabetes strategy that doesn't aggravate this risk.

Rather deadly vs. marginally deadly

We're not comparing apples and oranges here. Remember, food never enters the equation. The FDA is comparing a dangerous drug to a less-than-dangerous drug. That's why Avandia remains on the market. The FDA explained its reasoning in a commentary in the New England Journal of Medicine last week.

The FDA wants to keep Avandia (main ingredient, rosiglitazone) available because the drug alternative for advanced diabetes, Actos (main ingredient, pioglitazone), might cause bladder cancer. So if you are at risk of bladder cancer, the FDA reckons, you can give rosiglitazone a go; if you have heart problems, try pioglitazone.

Pity troglitazone is no longer around; that was taken off the market in 2000 for causing excessive liver damage. By FDA standards, this could be a viable option once your bladder and heart are shot.

Meanwhile, the use of meds is rising. The proportion of Americans using oral medication to treat diabetes increased by 28 percent from 1997 to 2007, according to numbers published earlier this month by the Agency for Healthcare Research and Quality.

Diet means "way of life"

The standard guidelines for treating diabetes do recommend diet and exercise as a first-tier approach. Unfortunately, doctors are not persistent enough — and many lack the training — to keep their diabetic patients on a strict regimen. The AHEAD study is unique in that it incorporates nutrition, behavior modification and monthly meetings with the study subjects.

A pill is the easier, yet ultimately less effective, route. It starts innocently enough: A doctor might prescribe the relatively benign drug metformin to control blood sugar. Then there's the eat-better lecture and see-you-next-year handshake. Other patients might get drugs containing sulfonylureas and the same lecture.

Without a serious lifestyle change, though, patients will soon find themselves on insulin and then some combination of drugs as they begin the slippery slope down the path of organ damage, be it liver, kidney, bladder, pancreas, or heart.

Maybe diet and exercise can't save all diabetics, but the combo gets far less credit than it deserves.

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