Medical Malpractice

How we diagnose diabetes in today's world is not an easy answer. The medical literature is dominated by studies looking for cutoff points. Over 120 systolic and you've got high blood pressure. Over 30 BMI and you're obese. Over 126 fasting blood sugar and you're diabetic. Cholesterol over 75 and you're on statins (ok..so maybe it's 200, but I'm sure there are those out there who would shoot for 75 if they could...)

Study after study after study. Literally BILLIONS of dollars are spent to determine at what point a patient becomes labeled with something. And, in today's society, being labeled = being on medication.

All of this labeling is the driving factor in all of medicine and the use of pharmaceutical treatment approaches. On the flip side, it is completely irrelevant to a physician who is going to facilitate lifestyle changes in a patient to improve their health and lower his or her risk of chronic disease.

Do I need to check a blood pressure or fasting glucose to make recommendations to a patient to avoid refined carbohydrates? Of course not. I have yet to be sued for malpractice for recommending lifestyle changes to a patient. (I can see it now...a heated jury trial. My patient on the stand stating, "But he made me eat more BRUSSELS SPROUTS!!" The collective gasp of dismay from the jury ensures the demise of my case...)

But from a mainstream medical standpoint, nothing is done unless there is a named condition. They are handicapped without the studies allowing the labeling of someone at risk and the subsequent cultural acceptance to use medication at this point. The ENTIRE system pivots around this concept.

So a recent commentary in the Journal of Internal Medicine laments the problem and the pros and cons with using HbA1c as a marker to determine diabetes. Or rather, using HbA1c as the marker to label a patient and begin pharmaceutical treatment.

But where is the problem??

HbA1c is a marker known as glycosylated hemoglobin. When sugar levels go up too high in the bloodstream, a reaction called the Maillard reaction irreversibly damages protein. As in "permanently". So, when we check HbA1c in a patient's bloodstream, we are actually checking how much hemoglobin has been irreversibly damaged by elevated sugar. But all we're checking is a single protein; every other protein of the kidneys, liver, brain, heart and pancreas is likewise damaged.

T-i-s-s-u-e d-a-m-a-g-e. Tissue damage. Tissue damage.

Yup. Pretty much anyway I read it, it's a bad thing. Lower is absolutely better. I don't care whether it's 10%, 7% (this is the treatment goal in diabetes) or 5.5%. I want it lower and I'm not going to hesitate to tell a patient to exercise more and eat less refined carbs to achieve this. I'm not going to wait until the percentage passes some magical point where THIS is when I start making recommendations to patients.

Read more the commentary here http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2012.02513.x/abstract