‘Rethinking Diabetes’ Review: Beyond Insulin
How best to manage a disease that is now more prevalent than ever? The key may be in our diets.
More than 100 years after the miraculous discovery of insulin to treat diabetes, how are things going? More people are getting the disease. (Between 1959 and 2021, the number of Americans diagnosed with diabetes increased from 1.5 million to 29.7 million, according to federal government surveys.) Patients are doing worse. (Fewer than 1 in 5 Type 1 patients are achieving blood-sugar goals established by the American Diabetes Association.) Diabetes intensifies America’s economic and racial divide. (Type 2 diabetes disproportionately affects the poor, the undereducated and minorities.) And the epidemic is global. (According to the World Health Organization, diabetes is the ninth leading cause of death worldwide.)
If any disease needs to be rethought, it is surely diabetes, and that is the premise of Gary Taubes’s latest book. A veteran science journalist who has now written five books on the relationship between diet and chronic disease, Mr. Taubes is not interested in the many other factors that undermine diabetic health, including access to care and the affordability of therapies. Instead he offers a unified theory on why patient outcomes are lagging. The key is food, specifically our overreliance on carbohydrates.
Mr. Taubes believes that diabetes is a cautionary tale for “the medicalization of modern life,” which unduly emphasizes pharmacology over diet and nutrition. We’d be much healthier, he argues, if we ate better and took fewer drugs. Whatever the practical limits of that goal—and I have my doubts—Mr. Taubes’s message is important and should be heard.
“Rethinking Diabetes” builds on arguments that Mr. Taubes has made in his other books, which allows him to tap into interviews he conducted as far back as 2004, and he seems to have read every study ever conducted on the relationship between food and diabetes. The research is impressive, but the accumulation of evidence can overwhelm. He devotes 35 pages to disproving the “saturated fat/cholesterol hypothesis.”
Mr. Taubes makes a convincing case that dietary fat has been given a bad rap since even before the insulin era began in 1921. Dr. Elliott Joslin, America’s leading diabetologist in the first half of the 20th century, was among those who believed that dietary fat either caused diabetes or made its complications worse. He believed that once insulin was discovered, its goal was to allow patients to increase their consumption of carbohydrates—which include such staples as bread, potatoes and fruit—without sugar appearing in the urine.
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The “demonization” of fat, Mr. Taubes writes, would only intensify in the decades to come as it was linked to heart disease, leading the ADA and other health organizations to prescribe diabetic diets high in carbohydrates and low in fat. The only problem is that carbohydrates increase your blood sugar, and elevated blood sugar—hyperglycemia—is exactly what people with diabetes are trying to avoid. The apparent solution is to take more insulin, but as Mr. Taubes explains, that’s not a good solution at all.
For a Type 1 patient, whose pancreas produces little or no insulin, injecting more of the hormone significantly increases the risk of low blood sugar, which can be dangerous, and injecting more insulin can also contribute to weight gain. For a Type 2 patient, whose body is resisting the insulin it’s already making, delivering more of it doesn’t address the body’s underlying problem of insulin resistance.
The hero of “Rethinking Diabetes” is Dr. Richard Bernstein, an engineer-turned-doctor who also has Type 1. In the 1970s, he became the first person to use a home glucose meter; looking at his data, he realized that a low-carb diet minimized his glycemic swings. For the past 40 years, in his books, academic papers and other advocacy, he has been the leading low-carb evangelist for people with diabetes.
But Dr. Bernstein is also a controversial figure, and not just because his nutritional guidance defied the medical establishment. I interviewed Dr. Bernstein and wrote about him in 2007. He’s prone to hyperbole and absurdities, such as his claim that insulin-pump patients “all have complications.” More important, his low-carb diet is uncompromising, and his advice is not realistic for everyone. When I interviewed him, he hadn’t eaten an apple since the Nixon administration. Nonetheless, I believe that Dr. Bernstein’s insights about diet and diabetes—and Mr. Taubes’s central argument—are correct. Imperfectly, I follow Dr. Bernstein’s guidance, and I’m far healthier because of it.
Mr. Taubes’s larger point is that we have allowed pharmacological miracles in the treatment of diabetes, insulin being one of them, to supplant food and nutrition as the foundation of good health. He concurs with Dr. Arnoldo Cantani, a 19th-century Italian physician, who said that the remedy for diabetes “is not in the drugstore but in the kitchen.”
But as Mr. Taubes notes in his introduction, a new class of drugs, GLP-1 agonists, are revolutionizing the treatment for both obesity and Type 2 diabetes. These drugs are expensive, they have side effects, and their long-term impact is unknown, but people can’t get enough of them. Would individuals be better off losing weight and controlling blood sugars with diet and exercise? Of course, but that ship has sailed . . . the buffet is lined with sheet cake, and the medicine cabinet is stocked with Ozempic.
I have one semantic nitpick. Mr. Taubes often describes patients as “suffering” from diabetes, as if all patients live in permanent distress and sorrow and are in need of pity. Personally, I suffer when a loved one dies, when either of our kids is unhappy and when my baseball team loses. But I don’t suffer from diabetes—I manage it through good days and bad and resolve to do better tomorrow.
Mr. Hirsch is the author of “Cheating Destiny: Living With Diabetes, America’s Biggest Epidemic.”