To the Editor: Samaras et al1 state that individuals at risk of diabetes and atherosclerotic cardiac disease can be identified simply and inexpensively by history-taking, physical examination, and very basic investigations. However, insulin resistance and beta cell failure are the hidden causes, and predate the development of overt diabetes by more than a decade.2 Doctors should help patients to understand that the progression of these conditions can be halted by significant changes to lifestyle.3 These will reduce the need for expensive medications, and in some cases even obviate their use.
As most obese individuals have battled unsuccessfully to lose weight, and non-obese individuals may also be insulin resistant,4 an assessment of glucose and insulin responses in an oral glucose tolerance test should assist the physician in developing a treatment plan. Unfortunately, few clinicians take the time to explain the difficult concept of insulin resistance.
Until the recent Enhanced Primary Care program, few individuals were able to afford the advice of dietitians or an exercise physio-logist. Most clinicians have given up attempts to motivate patients to exercise regularly and lose weight, and many take the easy course of prescribing medications. Although Reaven first described insulin resistance as the basic pathophysiology of type 2 diabetes in 1988,5 it is only since the advent of the glitazones that clinicians have embraced the concept. Furthermore, not one person with type 2 diabetes that I have encountered has heard of the term insulin resistance. An explanation of insulin resistance assumes new meaning when illustrated with a patient’s own glucose and insulin responses after a glucose drink or their usual breakfast.
Prescribing of metformin or other drugs and supplements should not be a first priority in controlling insulin resistance. Initial attempts should be directed at changes to diet, exercise and weight, with particular attention to loss of abdominal adiposity.
