Australia’s War on Type 2 Diabetes

In 2018 I met an everyday Aussie bloke whose story had a powerful impact on me. Neil Hansell constructs light machinery for a living. He has a wife and four kids. He also has type 2 diabetes. A few years ago, diabetes changed Neil’s world overnight. Neil is just one of the estimated 1.5 million Australian’s living with type 2 diabetes – the sixth biggest killer in our country, a growing epidemic, and the greatest threat to our health system.

Gangrene of the feet, amputation of the lower limbs, impotence, kidney failure, heart attack and stroke are just some of the other life-changing or life-threatening complications that menacingly await people with this insidious disease

Unfortunately, Neil had neglected his disease and he paid the price. He went to sleep one evening with normal eyesight and woke up the next morning blind in both eyes. One of my surgical colleagues worked hard to retrieve his sight, however sadly, it was too late. At the age of 50, Neil was faced with the rest of his life in darkness, and all that he can see now are black objects on a grey background. Neil had to give up coaching javelin, a hobby and a passion that gave him so much pleasure. He lost his driving licence, his independence, and his ability to see the beautiful smiles on the faces of his grandkids.

Neil is not alone. Over half of all Aussies with diabetes are not having their regular all-important sight-saving eye checks. As a result, it’s now the leading cause of blindness amongst working age adults in this country. It’s also the fastest growing cause of blindness in Indigenous people.

Gangrene of the feet, amputation of the lower limbs, impotence, kidney failure, heart attack and stroke are just some of the other life-changing or life-threatening complications that menacingly await people with this insidious disease.

Dealing with the complications of diabetes is expensive (the total annual cost impact in Australia is estimated to be close to $20 billion) and is counter intuitive. We should all be aware of the risk factors that underlie most cases of diabetes and how we can prevent the disease in the first place, rather than waiting for the complications to arise before we act.

WHAT EXACTLY IS DIABETES?

The word diabetes comes from the ancient Greek phrase “to pass through” and suggests excessive urination, one of the earliest symptoms of the disease.

There are two main categories of diabetes:

Type 1 diabetes, which makes up 10% of all diabetes, is due to auto-immune damage to the pancreas – the organ that secretes insulin into the bloodstream. Insulin is the hormone that’s responsible for moving dietary glucose from the blood into every cell of our bodies where it’s stored and used as an energy source. Without insulin, blood glucose levels rise dangerously, and this can be life-threatening. The onset is usually rapid and can happen at any age.

Type 2 diabetes, which makes up nearly 90% of all diabetes, is a progressive metabolic disorder where the body becomes resistant to the effects of insulin. Modifiable risk factors include an unhealthy diet (too much added sugar and refined carbohydrate), physical inactivity and weight gain (a gain of 20–35kg increases the risk by 11,300%).

Importantly, there is strong evidence that we can prevent the development of type 2 diabetes with lifestyle behavioural changes. The remainder of this discussion will centre on type 2 diabetes.

WHY IS TYPE 2 DIABETES ON THE RISE?

Humans are physiologically hardwired to love and seek out sweet things. It’s an ancient survival mechanism that evolved to prepare our bodies for expected periods of fasting when food supplies were scarce, and to warn us off bitter and potentially poisonous foods.

Once a person has been diagnosed with type 2 diabetes, it can be managed successfully in many people without medications or surgery – with dietary modification and increased physical activity

Prior to the 1600s, sugar was an expensive commodity, the domain of healers and holy men or an indulgence that could only be afforded by the wealthy and powerful. Its rising availability and popularity over the next three centuries, as a result of the booming sugar trade, led to diminishing costs, turning sugar from a luxury item into an everyday necessity.

Things took a turn for the worse in 1980, in large part due to the Dietary Guidelines for Americans, which were released that year in response to the escalation in heart disease that had been noted in the decades following World War 2. Based on little scientific evidence, the recommendation was to reduce dietary fat to less than 30% and increase consumption of carbohydrates to 60%. The result had an effect that was opposite to that intended – heart disease and type 2 diabetes soared. Globally, there has been a four-fold increase in type 2 diabetes since 1980. And the growth has been even more profound in some communities and countries.

The increasing intake of cheap and highly processed foods, supplemented by an explosion in the consumption of sugar-sweetened beverages (Australia’s consumption of sugary drinks increased by 30% in the decade to 2017), and coupled with a more sedentary lifestyle (‘the sitting disease’), has been catastrophic to our health and to the productivity of global economies.

In many parts of the world, including Australia, type 2 diabetes is present in nearly one in every ten adults. Half of all adults in the US, and in some parts of Australia, have either diabetes or pre-diabetes, for the first time ever. In Australia, there are over 1,100 teens and children with type 2 diabetes, a disease previously only seen in mature aged people (hence the former term ‘maturity-onset diabetes’). There’s even been a reported case in a three-year-old child.

Among the Indigenous people of Australia, there’s been an 80-fold increase in type 2 diabetes since 1980 with the disease now affecting teenagers and primary school children as well as adults. A diet that’s high in sugar and refined carbohydrates undoubtedly underlies this concerning increase. Sadly, this dangerous diet is all too common in remote communities, where sweet products are in abundance and fresh and healthy foods are scarce and expensive.

HOW DOES EXCESSIVE SUGAR CONSUMPTION CAUSE TYPE 2 DIABETES?

Simple sugars (monosaccharides) are single molecules such as glucose and fructose. Complex sugars (polysaccharides), are chains of sugar molecules, as found in table sugar (sucrose), high fructose corn syrup (HFCS), refined flour, white rice and potato. Sucrose and HFCS are made up of short chains of glucose and fructose, in equal amounts, and starch is composed of long chains of glucose. These sugar chains are broken down in the gut and their glucose and fructose are then absorbed into the bloodstream.

As the blood glucose level rises following the ingestion of any sugar, the insulin level temporarily rises in order to move the glucose into our cells (especially the liver, skeletal muscles, and pancreas), where it’s used for energy or stored for later use. With excessive and persistent glucose intake, the cells become ‘full’ and can no longer take in more. The overflow of glucose is ultimately converted into fat by the liver, where it accumulates, and can rapidly give rise to fatty liver. The French delicacy foie gras is fattened goose liver, created by force-feeding these unsuspecting birds with excessive levels of refined carbohydrates in the form of high starch corn meal. Foie gras is produced in geese in less than two weeks. Humans can develop fatty liver within two months.

Fatty liver can in turn, give rise to insulin resistance as more and more insulin is required to deal with the glucose overflow. More and more fat is subsequently created by the liver.

Fructose is the sugar that gives sucrose its sweetness. It makes up at least half of all the sugar we ingest, is not recognised as food by the body, has no nutritional value, and is not under hormonal control. Indeed, it suppresses our appetite control system. Fructose is only metabolised by the liver, is immediately converted into fat, and can act directly to cause fatty liver.

The excess fat created by glucose and fructose is exported from the liver as harmful triglyceride in the form of very low-density lipid, and is deposited in and around the abdominal organs as visceral fat, which is far more dangerous than subcutaneous fat. The resulting increase in the waistline is a strong predictor of type 2 diabetes. Indeed abdominal or visceral obesity is part and parcel of the same disturbed metabolic process.

Type 2 diabetes takes, on average, 13 years to develop in adults following the onset of insulin resistance, however in children and teens the disease can develop within two years. The diagnosis of type 2 diabetes is often made years after the onset of the disease – it’s common for people to have type 2 diabetes for five to seven years before diagnosis. Fatty infiltration of the pancreas impairs insulin production and eventually results in a measurable increase in the blood glucose level. The ensuing hyperglycaemia (high level of glucose in the blood) leads to the characteristic early symptoms of excessive thirst and urination, and drives continued insulin production. The vicious cycle of metabolic dysfunction progresses, and the sustained hyperinsulinemia (high level of insulin in the blood) is responsible for many of the severe and life-threatening complications of type 2 diabetes.

Persistent hyperinsulinemia and hyperglycaemia will, in time, damage the fine blood vessels throughout the body, resulting in numbness and pain of the extremities, impotence, kidney failure, blindness, and dementia. Hyperinsulinemia itself predisposes to the development of atheroma (fatty plaques) which can block the major blood vessels, leading to gangrene of the feet and amputation of the lower limbs (peripheral vascular disease), heart attack, stroke and death. It also plays a role in the causation of other diseases such as Alzheimer’s disease, hypertension and cancer. Type 2 diabetes truly ravages the entire body.

PREVENTION AND CURE OF TYPE 2 DIABETES

Naturally occurring dietary fats, such as those found in avocado, nuts, olive oil, eggs, milk, butter and cheese, have never been linked to cardiovascular disease. Furthermore, low fat/low calorie diets have proven to be universally unsuccessful – lowering your caloric intake simply lowers your metabolism.

What’s extraordinary, and surprisingly little known, is that minimising your ingestion of sugar, refined carbohydrates, and highly processed products containing these substances, can prevent fatty liver, insulin resistance and type 2 diabetes. It’s proven and powerful.

we cannot let commercial interests stop us from acting to prevent type 2 diabetes in children, young people and the community in general

Once a person has been diagnosed with type 2 diabetes, it can be managed successfully in many people without medications or surgery – with dietary modification and increased physical activity. There’s good evidence that dietary modification and regular periods of timerestricted eating or short-term fasting (as our ancestors experienced) can help. There are several approaches to giving up sugar and for fasting, with plenty of books, social media platforms and apps to help, however if a patient is on any medication for type 2 diabetes, fasting should only be undertaken with guidance from a treating doctor.

I do like the analogy of a leaky tap – we don’t invent elaborate mechanisms to deal with the overflow of water from a leaking tap, we search for the source of the leak and fix it. In type 2 diabetes, this means finding the root cause for the hyperglycaemia and hyperinsulinemia – excessive dietary sugars – and fixing that. Reducing intake of sugar reverses fatty liver, hyperinsulinemia and hyperglycaemia, and can mean that medication or other treatments are no longer needed. Type 2 diabetes can even be reversed in many people.

THE “FIVE A’S” OF SUGAR TOXICITY

Type 2 diabetes is a dietary disease and a dietary disease needs a dietary cure. Sounds simple right? Unfortunately, not. There are other confounding factors that make this a tougher ask and they are related to the toxic impact of sugar. I call them the “Five A’s” of sugar toxicity – addiction, alleviation, accessibility, addition, and advertisement.

I suspect that much of the human race is addicted to sugar, although I’m sure not many of us realise we are. That’s because sugar and other sweet products are highly addictive. In fact, sugar has been proven to be as addictive as the nicotine in cigarettes. Like nicotine, alcohol and drugs, the consumption of sugar activates the reward centre in our brains, resulting in the release of endorphins and feel-good chemicals such as the neurotransmitter dopamine. Because sugar makes us feel good, it’s often used as solace when we’re down or for the alleviation of stress. It gives us an endogenous dopamine hit which counters the cortisol released during anxious times. This in turn makes us want to do it again, as it feels good. It also gives us cravings. And it’s the good feelings and the cravings that conspire to make sugar a very difficult habit to kick.

The problem is, the more sugar we ingest, the more we need to make us feel good. It’s a vicious cycle that’s hard to break and often drives excessive and sustained consumption.

These days it seems that our whole world is flooded with cheap and highly accessible sugary food and drinks. In the US, 75% of all food and drinks have added sugar and I suspect that Australia is not far behind.

You can’t walk into most service stations without being confronted by a wall of confectionery and you can’t check out from most supermarkets and many stores without being enticed by chocolates and soft drinks, often at heavily discounted prices.

Our love affair with sugar is also exacerbated by the relentless barrage of advertisements for sweet products that flood our every waking moment, often in a predatory manner, and the lure of fast and convenient foods in our busy lives.

DEALING WITH SUGAR TOXICITY

It’s not impossible to kick the toxic impact of sugar – there are strategies that can be taken on at a personal level, and strategies that must be taken on by business, industry and government. Ultimately, it requires a team approach and it necessitates resilience and innovation.

Let’s look at strategies that can deal with the “Five A’s” of sugar toxicity.

Personal Strategies 

At the personal level, it’s a matter of being aware of our own addiction to sugar and slowly winding down from it. Going cold turkey from all sugar would be seriously difficult to achieve given the amount of sugar added to our food and drinks. During my detox, I began with omitting the obvious foodstuffs that are loaded with sugar – soft drinks, fruit juices, dried fruit, chocolate, candy, ice cream, cakes and sweet biscuits – and avoiding granular sugar itself, for example I stopped sprinkling sugar on my cereal and stirring sugar into my tea and coffee – now I think coffee tastes better without sugar!

Even these simple strategies are likely to cause withdrawal symptoms such as irritability, headache, sluggish thoughts, and fatigue, which often begin on the very first day. When I detoxed from sugar, it felt like I was trudging through concrete. And the cravings were unpleasant. It was much tougher than a coffee withdrawal, however it only lasted for three days, and the occasional paracetamol tablet certainly helped.

Progressing to the next level might include cutting out commerciallyproduced everyday foodstuffs that contain excessive amounts of added sugar such as jams, condiments, most breakfast cereals, and heavily-processed foods that contain refined carbohydrates such as products made from white flour (white bread, pastries and pasta) and white potatoes (crisps and fries). White rice is also heavily refined and as such is pure starch. I’m certainly not a saint when it comes to eating sugar and carbs (my in-laws call me the “Ice Cream Kid”), however I most definitely don’t want to contract type 2 diabetes, so for me, “move more, eat less sugar” is a good rule to live by.

It helps to be aware of the times when we’re consuming sugar that are linked to a habit, particularly a pleasurable one such as eating a bag of sugary treats at the movies or a block of chocolate in front of the TV, and definitely avoid snacking on sugar or using it as a reward for a job well done. Why not replace that bowl of sugary treats on the kitchen counter or staff tearoom with a bowl of nuts, or eat an apple instead of drinking a glass of fruit juice (although whole fruit contains fructose, it also contains healthy doses of fibre, vitamins and other goodies).

It’s also important to be aware of the times when we’re using sugar to make ourselves feel better or to alleviate stress. The brain doesn’t care where the feelgood chemicals come from to balance the cortisol permeating our bodies during anxious times – there are plenty of other options to replace a scoop of ice cream, bar of chocolate or can of soft drink. Going for a walk, run or cycle, listening to your favourite playlist, watching a comedy, or doing a positive deed, can all make us feel good through the same internal mechanisms used by sugar, alcohol and drugs.

Public Health Strategies 

From a public health perspective, the government must play a pivotal role. A multi-disciplinary think tank is needed, and one that engages medical doctors such as endocrinologists and public health physicians, neuroscientists, nutritionists, marketers, PR experts, and government representatives. Strategies at this level should be aimed at the ‘accessibility’, ‘addition’ and ‘advertisement’ “A’s” of sugar toxicity.

Ultimately, it’s about business, industry and government being accountable. Avoidance of environmental cues that trigger addictive thoughts and feelings is critical to support recovery from any addiction, including detoxing from sugar. Making sweet products less obvious and accessible in supermarkets, delicatessens, post offices, office supply stores and service stations would be a good start – moving them away from checkout counters means that those impulse purchases are less likely to happen. Vending machines dispensing sugary food and drinks should be removed from government buildings, schools and universities.

A system for clear labelling of the added sugar content of products should be implemented – the current nutritional guidelines on packaging offer no insight into the amount of added sugar contained within. I like the idea of a ‘traffic light’ rating for the level of added sugar, where red = harmful, orange = think twice, green = safe. In Australia, we have a five-star health rating system, which is voluntary, and as such is flawed. A number of unhealthy products are incorrectly rated as healthy within this system – for example, orange juice receives five stars, and yet a glass of orange juice has nearly as much sugar as a glass of cola. Without enforcement, this is hardly surprising – what manufacturer would voluntarily put a low rating on a food that it’s trying to sell?

Applying a levy to products containing high levels of added sugar should also be considered. There’s good evidence and sound reasoning behind this. Sugar sweetened beverages have been linked to the development of type 2 diabetes, and there’s now strong, increasing and consistent evidence that a levy on sweet drinks will effectively reduce consumption. Such a levy would also help to offset the massive cost to our health system and raise much-needed revenue for awareness initiatives.

Advertising time and space for sugary products should be minimised, as it has been for cigarettes, starting with the cessation of these advertisements targeting children on the internet and free-to-air TV, and all the places our kids see the pernicious promotion of sugary products as ‘normal’. Advertisements promoting these products should also be removed from government facilities and services, such as trams and buses.

Powerful and hard-hitting multi-media awareness strategies should be introduced, once again as we have done for cigarettes. These will inform the public of the farreaching health dangers of sugar (check out Sight For All’s 2018 TV commercial at sightforall.org/news/diabetic-retinopathyinitiative) and the very serious complications of type 2 diabetes. Multi-media strategies should also be used to communicate the positive, reassuring news that type 2 diabetes can be prevented and is often managed without medications or other treatments.

While the sugar industry and the food and beverage industries need to be included in discussions, we cannot let commercial interests stop us from acting to prevent type 2 diabetes in children, young people and the community in general. Resilience and innovation will be necessary to re-direct the focus of these industries, as has occurred in other disrupted industries. Perhaps sugar cane, for example, could be used to produce ethanol as a clean energy source.

This epidemic is the biggest health challenge facing our country, and indeed the world. It’s time for Australia to declare war on type 2 diabetes.

Dr James Muecke AM trained as an ophthalmologist in Adelaide and undertook subspecialty training in oculoplastic surgery and ocular oncology in the United Kingdom. A Fellow of the Royal Australian and New Zealand College of Ophthalmologists and a member of the International Society of Ocular Oncology, he is also the founding Chairman of Sight For All, a not-forprofit organisation dedicated to fighting avoidable blindness in the world. 

Dr Muecke’s commitment to social impact and humanitarian endeavours has earnt him a string of awards including an Order of Australia in 2012, the Australian Medical Association’s President’s Leadership Award in 2013, Ernst & Young’s Social Entrepreneur for Australia Award in 2015 and The University of Adelaide’s Distinguished Alumni Award in 2019. In 2019 he was named South Australian of the Year after which he was named the 2020 Australian of the Year.