Diabetes, Cholesterol, BP: Normal is no longer normal

Pre-diabetes

On 10 June 2014 there were global headlines about a ‘condition’ called pre-diabetes. From the Mail telling us that “A third of adults have ‘borderline’ diabetes – but most don’t know: Rising tide of obesity means number who have ‘pre-diabetes‘ has trebled since 2006″ to the Huffington Post proclaiming “Most People In England Have Borderline Diabetes, New Study Reveals“.  One third was never most people when I did proportions, but anyway.

Here is the summary of the study and findings from a journal web site and here is the original (full) article.

A quick review of the article should have made the media far more challenging, instead of just taking the press release headlines:

1) The study used data already gathered for Health Survey England (HSE), which started in 1991. The number of adults involved in the HSE, from whom blood samples were taken, was 7,455 in 2003; 6,347 in 2006 and 1,951 in 2009. I can’t find the numbers for 2011, but they are likely to be small if the trajectory continues. There are over 40 million adults in England. Using 2009 as a guide, projections on this concept of ‘pre-diabetes’ have been made based on 0.0048% of the population. I can’t get my head around such numbers.

2) People were diagnosed with pre-diabetes if they had glycated haemoglobin (an indicator of blood sugar levels) between 5.7% and 6.4%. This is the US guideline for ‘pre-diabetes’. The UK guideline is 6.0-6.4%. This would have over-predicted the idea of having a pre-condition.

3) The introduction to the full article in the BMJ is worth a read. The introduction notes that England set up a scheme to offer people aged between 40 and 74 a health check to try to pick up blood glucose concerns (and other things). Then it admits that “the scheme is controversial since randomised trial evidence does not show that health checks reduce morbidity or mortality.” i.e. these health checks made no difference to health or death. The article then notes the concern about “the extent to which medicine is extending the boundaries of illness through new definitions of disorders, with a consequent risk of treating more people than necessary.” I couldn’t have put it better myself. That should have been the headline.

The issues with the headlines on pre-diabetes aren’t, however, the main focus of this post. This post is about the fact that normal is being redefined as abnormal to the point that normal is no more. The whole concept of pre-diabetes is just one example and it’s by no means the first distortion in the diabetes world…

Diabetes

Aside from this created condition of pre-diabetes, the definition of diabetes itself has been manipulated. There’s a useful diagram here (scroll about half way down), which has a clear illustration of the game being played.

The curve in this graph is known as a “normal distribution”. This means that, when we plot the population, people are normally (typically) distributed as this curve indicates – most people are in the middle and fewer people at both ends. The peak of the hump indicates the average (mean and mode in this case if you like stats). The average fasting blood glucose level is 100 mg/dL (this is the US measurement – UK would be 5.6 mmol/L). Don’t worry about the mgs and the mmols – we’ll just call them US and UK measures from now on. So 100 (US)/5.6 (UK) is the true average of the population. There are very few people with a fasting blood glucose level of 50 (US) and about the same number of few people with a fasting blood level of 150 (US) – most people fall within the 60-140 range (US) (3.3-7.7 UK).

Then see what has happened. Diagnosis of diabetes used to occur at a fasting blood glucose level of 140 (US) 7.8 (UK). This is a number on that normal distribution curve and so is an entirely normal reading for a section of the population. Normal was redefined as high. But then it got worse. Back in 1997, high was re-re-defined as 126 (US) and another large segment of entirely normal people became abnormal.

The UK uses the same benchmark to diagnose diabetes. This states that diabetes is diagnosed at a fasting blood glucose level above 6.9 UK (126 US). If you look at what the UK thinks is normal, it is arguably worse than the US graph. The UK has defined normal fasting blood glucose levels as 4.0-5.9 (72-106 US). The true centre of the norm from the graph is 100. The range which captures most people is thus 80-120 – not 72-106.

Normal is not normal. The medical world has overruled the human population and decreed that normal is not normal. Normal is now high and people shall be treated accordingly. Now that we have pre-diabetes on top, joy of joys, we can start medicating people even sooner than our re-re-defined norm would otherwise let us drug them. (Or we can give them ‘base your meals on starchy foods’ dietary advice and speed up their pathway to type 2 diabetes.)

Cholesterol

This doesn’t just happen in the world of diabetes. Cholesterol is perhaps the most successful and horrific redefining of normal that the medical world has ever got away with. Look at figure 2, on page 3 of 5, here. It’s a graph of the normal distribution for cholesterol in the UK. There are two lines – one from the Health Survey for England and the other for The Health Improvement Network. The high point of the chart (the average) is 5.6 mmol/l (216 mg/dl) for the Health Survey for England and 6.3 mmol/l (243 mg/dl) for The Health Improvement Network. Both the red and blue lines follow a normal distribution (slightly skewed) with readings between 2 and 10. Can you imagine the reaction of your doctor if your cholesterol reading were 9-10 mmol/l (that’s 348-387 mg/dl)?! And yet it is absolutely normal that a section of the population will have this as their normal reading, just as a section will have a normal cholesterol level of 2-3 (77-116 mg/dl).

Just as happened with diabetes, normal is not allowed to remain normal. The medical profession has redefined cholesterol to be high at the absurdly low number of 5 mmol/l (193 mg/dl). You can see from the graph that only a small proportion of the population would have a cholesterol level below 5 in normal circumstances. Indeed, if you look at government data measuring people against this made-up target – the Health Survey for England for example (summary of key findings) – we have the crazy situation (page 22) where it is noted that 80% of men and women in many age groups have cholesterol levels above the government target of 5.0 mmol/L. That’s not because 80% of people have ‘high cholesterol’, but because normal has been redefined as high so people cannot be normal any more.

Look at what has happened in America. In 1960-62, normal (average) cholesterol levels for 60-74 year olds were 250 mg/dl (6.5 mmol/l). After decades of statinating people, ‘normal’ cholesterol levels have been reduced to approximately 215 mg/dl (5.6 mmol/l) for this age group, by 1999-2002.

You know why this happens. Normal people have no value whatsoever to the pharmaceutical industry. But redefine ‘normal’ as hi gh and suddenly healthy people can be medicated. This is how Lipitor was able to earn $125 billion for Pfizer during its patent. And who sets the targets?

In America, they are set by the National Cholesterol Education Programme (NCEP). The 2004 NCEP financial disclosure report reveals that ALL members of the 2004 guideline participants had received payments and/or grant funds from some, many or most of the following organisations: Abbott, Astra Zeneca, Bayer, BMS-Sanofi, Bristol-Myers Squibb, Esperion, Fournier, Glaxo SmithKline, Kos, Lipid Sciences, Merck, Novartis, Pfizer, Procter & Gamble, Reliant, Sankyo, Takeda, Tularik, Wyeth. (For full details of conflicts see point 3 on this post.)

In the UK they are set by the National Institute of Clinical Excellence (NICE). Here are their conflicts – 8 out of 12 of the NICE panel members have conflicts of interest with the statinators.

Blood pressure

Blood pressure is the same. Here is a journal article with a couple of very interesting graphs – open up figure 1 and figure 2. Figure 1 is the higher number when you have your blood pressure reading (the 140 in 140/90 kind of thing). This shows that the normal blood pressure range for the general population is anywhere from 90 to 240 as the top number, with 130 being the most common reading (mode) and the average (mean) being around 140.

Figure 2 is the lower number (the 90 in the 140/90) and this ranges from 50 to 130. The most common is around 85 and the average is around 90. So the true average blood pressure (BP) in the normal population is approximately 140/90. You may be aware that 140/90 is the definition of high BP. Yet again, normal has become high and now everyone who is deemed high shall be medicated, when they are in fact normal.

Height and foot size

In the Western Journal of Medicine, (May 2002) Thomas Samaras and Harold Elrick posed the question “Height, body size and longevity – is smaller better for the human body?” The study took 100,000 males from 6 different ethnic populations – in the same city (California) to try to normalise other factors. The table had the following height orders (tallest first): African Americans; White Americans; Hispanics; Asian Indians; Chinese and Japanese (the first two groups were recorded as of equal average height – 70 inches).

The death rates for all causes and coronary heart disease (CHD) were presented in the study. A clear pattern was immediately obvious. I calculated the correlation coefficients as 0.85 for height and CHD and 0.9 for height and all causes of death (1 is a perfect relationship – scores of 0.85 and 0.9 are very strong relationships).

What if we concluded that height were a cause of CHD (and all causes of death) and that we should therefore redefine the average height to declare the actual average of 69.7 inches (for all American men) to be abnormal? What if we made up a new target 10% lower than the actual average and decreed that normal height should be 63 inches? We could then administer drugs to stop growth hormones from doing their job. I trust that this analogy disturbs you and yet…

The Chinese practice of foot binding – an artificial intervention in the normal development of the human body, to achieve an artificial ‘norm’ – was thankfully outlawed in the early twentieth century, but trying to reduce many other genuine human norms – from diabetes to BP – has now become common practice and big business.

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16 comments on “Diabetes, Cholesterol, BP: Normal is no longer normal
  1. avatar Zzg00gzz says:

    I’m going to write some trap/dubstep/gabber songs that speak out against the pharmaceutical industry and warn the public to be aware of this and to not let their children become a victim. Basically, we’re just guinea pigs they like to torture with their experiments…out of pure entertainment and profit!

  2. avatar Paul says:

    If there is a correlation between height and CHD, then perhaps there is an argument for compulsory amputations below the knee in order to bring ‘at risk’ groups back into the ‘normal’ range.

  3. avatar Ash Simmonds says:

    *checks pharmaceutical patents*

    Nope, no patented drugs exist for lowering body temp yet (whilst subject remains alive), guess it’s still ok to be 37 deg C.

  4. avatar Hugh Mannity says:

    So if the normal range for fasting blood glucose is higher that currently espoused by the disease management industry, does that also mean that the “hard” number of 140 (US) or 7.8(UK) at which organ damage begins, is also inaccurate?

    Because it would seem to me that if normal biochemistry can vary that much, then the body’s organs should be similarly flexible. Rather than there being a hard line at which organ damage occurs, perhaps it’s n% higher than fasting.

    Similarly, just having the occasional peak where post-prandial blood glucose exceeds this “magic” number is unlikely to cause lasting damage. Lasting organ damage comes after substantial and prolonged abuse. But just how substantial or prolonged, is going to vary from individual to individual.

    Modern medicine doesn’t like squishy numbers. Especially the bean-counter driven American healthcare system. They’re all about hard numbers and “pay for performance”. It’s a very mechanistic model, which is fine if you’re talking cars or vacuum cleaners, but doesn’t work nearly so well with people.

    • avatar Zoë Harcombe says:

      Good point Hugh!

      • avatar Andrés says:

        Both of you should read Jenny Ruhl’s links.

        It is well known that turning from traditional food to industrial one wrecks havoc with our glucose tolerance and health. Just read late Barry Groves’ Trick and Treat or even Lindeberg, Cordain and Eaton’s Biological and Clinical Potential of a Palaeolithic Diet. Our western normal is clearly not healthy.

        Personal information through postprandial measurement is the way to go if we are interested in knowing if this occasional peak exceeds this “magic” number either just barely and not often or instead sharply and often. Why? Because it is quite clear that the deleterious effect is dose-dependent: read Petro’s take on the matter.

        It is highly irresponsible to suggest people their fasting blood glucose of 140 (7.8) or even 120mg/dl (6.7mmol/l) is OK.

  5. avatar Kenny says:

    Zoe, there seems to be at least some good news recently on the blood pressure issue.

    With Blood Pressure, Lower Is Not Always Better, New York Times

    http://well.blogs.nytimes.com/2014/06/18/with-blood-pressure-lower-is-not-always-better/

  6. avatar Andrés says:

    I will add the most relevant links to Jenny Ruhl’s work.

    In Misdiagnosis By Design – The Story Behind the ADA Diagnostic Criteria explains what Pam pointed out: “Therefore the “norms” were set at a high level.”

    In How Blood Sugar Control Works–And How It Stops Working explains what Judi pointed out: “According to Jenny Ruhl at Bloodsugar 101 by the time your fasting blood sugar is this high you are already most likely getting damaging post-prandial numbers of over 140.”

    In Research Connecting Organ Damage with Blood Sugar Level explains what those troubles are that Janknitz pointed out: “So they may be under 100 FBG and therefore “normal” on that curve, but they are already in trouble.”

    Under an unhealthy diet normal can be unhealthy. Everyone should check his/her postprandial blood glucose after most usual meals and act accordingly.

  7. avatar Pam Forrester says:

    I agree with Lauren and Janknitz. Lowering norms for FBG is a good thing. From what I have read Doctors were loathe to diagnose diabetes too early b/c of the ramifications on getting health insurance costs/death sentence perception ages ago. Therefore the “norms” were set at a high level. But as others have said damage to blood vessels, capillaries, organs, pancreas etc occurs earlier than most people think according to Blood Sugar 101. And just as Lauren said, Fasting Blood Glucose is the last thing to go after years of sugar organ damage.

    This is what I have read. Jenny Rhul has diabetes and great difficulty regulating it with diet and medication. Zoe, I agree with you, we do not want to medicate more and more people. We need to change our diets. The Diabetes Diet needs to be changed to decrease the need for medication.

    But I don’t think we need to raise the FBG norms. But I could be wrong. Jenny Rhul could be wrong. Could you do more of your wonderful research on this issue and let us know what you find?

  8. avatar Lauren says:

    I get what you are saying, but I am wondering what the “normal” population has been doing. I mean, has the normal curve been going upward, or has it been staying in the same place? I would guess that, at least for blood sugar, it has been straying upward, since so many people eat so many carbohydrates. So, perhaps, docs have been moving it BACK down to where it should be, or to where it used to be?

  9. avatar Judi O says:

    I agree with Janknitz, a fasting glucose number over 100 is a call to action. According to Jenny Ruhl at Bloodsugar 101 by the time your fasting blood sugar is this high you are already most likely getting damaging post-prandial numbers of over 140. By the time I took matters into my own hands and changed my diet I was already suffering from neuropathy in my feet. I was not considered a diabetic – my doctor had told me my fasting was “high normal” at 102 and we would just keep our eye on it. Right.

    When I began testing after meals I discovered my sugar was going as high as 182. My doctor didn’t seem concerned by this, but I began a primal style diet and have never looked back. Metformin can be helpful, but it’s mostly about how much carbohydrate you’re eating and doing some sensible exercise.

  10. avatar Janknitz says:

    I GET what you are saying, and I totally resent that my doctor is now telling me that my BP of 130/90 is now considered “pre-hypertension” when it used to be considered “normal”. They want to treat what was once considered normal. Ridiculous considering this is how high it goes with “white coat syndrome”. At home my BP typically runs in the 115/70 range–I’d be passing out all over the place if they tried to lower my “pre-hypertension” BP! Likewise for the changes in what is considered “normal” cholesterol, especially that no allowances are made for age, especially in women.

    OTOH, I do believe that there is a “diabetes spectrum” and that people who are considered “pre-diabetic” under the current standards are definitely on that spectrum (personally, I think HbA1C’s in the 5.7 range indicate they are already diabetic, but that is a personal opinion). Additionally, the so-called “normal” curve includes a lot of people who already have serious insulin resistance issues and do tend to be hyperglycemic, but maybe not when fasting–yet. So they may be under 100 FBG and therefore “normal” on that curve, but they are already in trouble. I have read that if you tested strictly a population of people who do NOT have insulin resistance, that the “normal” part of the FBG curve would range from about 70 to 85, not up to 100.

    I don’t think people need to be on diabetes drugs just because they are “on the spectrum”. But they certainly need to be paying attention to their diet and exercise AND be given the RIGHT diet advice, which doesn’t include eating low fat and lots of whole grains.

  11. avatar Lynne says:

    Zoe, thank you for this, as usual an informed and sensible response.

    • avatar Lisa Chase says:

      What a coincidence: I’m currently reading a book called “The Patient Paradox” by Margaret McCartney. I’ve only just started it, but she writes about something similar- that the medical industry nowadays seems to be treating “numbers” rather than actual symptoms or sickness. (For instance, so-called “high cholesterol” is not an actual illness, and yet millions of people are being treated as if it were). Not only that, but one blood reading can vary drastically from day to day, or even hour to hour; it’s just a “blip” in the greater scheme of things. In addition, there does not seem to be any evidence that medically lowering blood cholesterol or blood pressure does anything at all, aside from causing possible side effects- (pre-diabetes could be a different case IF they were to advise people with high blood sugar to reduce carbohydrates, but of course they don’t).

      On a side note, I am now considered “underweight” because my BMI is below “normal”. But I feel perfectly healthy, and when I look at film footage of women from the 1950’s or 60’s, my body type looks average for that time period. So what is “abnormal” anyway?

      • avatar Zoë Harcombe says:

        Hi Lisa – sounds like a great book – I do like M McC – one for the holiday downloads – thank you!

        In terms of health, overweight (25-30) is ‘better’ (Lenz M, Richter T,Mühlhauser I, ‘The Morbidity and Mortality Associated With Overweight and Obesity in Adulthood A Systematic Review.’ Dtsch Arztebl Int. 2009 October; 106(40): 641–648. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770228/) than underweight or normal. But anyone who is eating well and is finding a stable weight easy to maintain is probably at their natural weight. In some people this is low; in some it’s high. That’s why we have averages!

        Best wishes – Zoe

        • avatar Lisa Chase says:

          Hi Zoe,

          I had also read that being overweight is probably healthier than being underweight, particularly in muddle aged people. However, the only way I am able to “up” my weight is by eating sugar and refined carbohydrates, which I don’t want to do for obvious reasons! In fact, as soon as I stopped eating sugar and replaced it with healthy fats, I dropped down to this weight. (However, I feel much better eating this way!) One of the points I was trying to make though is that “averages” and what’s considered “healthy” might change over time, so there’s probably little point in stressing about it; for instance, my body type and weight looks like it was “average” for women of my age in the 1950’s and 60’s, if not now. To be honest, I was always a bit skeptical of BMI as a measuring tool (both for labeling “overweight” as well as “underweight”)- just as I am skeptical of other “numbers”.

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