Dr. Leahy: So this is a fundamentally important question and one that I think the average primary care doctor sort of knows in his heart, or her heart, is important, but tends to discount it because it’s so hard to understand what to do with this in a clinical practice and make it effective. 

You know, from a scientist point of view diet and exercise should be hugely important especially early in the course of the disease and the simple reason is the following: If you sort of think about what’s happening at that time you’ve got a certain level of insulin demand, i.e., tissue insulin sensitivity or resistance and you’ve got a beta cell that’s able to act at a certain level of function or compensation.  And people who are early in the stage of the disease, it’s not normal, but it certainly is some.  People can compensate some.  And so, if you come in, you can either try and promote better beta cell function and certainly that’s an ongoing issue that we’d like to think about with some of the beta cell specific drugs maybe early in the course of the disease, and I think in the future we’ll have a better idea where they fit, but in today’s world that’s not what we do. 

In today’s world we think about trying to lower the demands on the beta cell.  And it could be done pharmacologically so there’s metformin is used some -- clearly many providers know of metformin’s use.  I have said previously -- I write about that TZDs actually have proven to be incredibly beneficial early in the course of the disease, but they’re complicated because they have side effects and they’re expensive. 

So the least expensive, in theory, the most applicable, in theory, and the one which is the safest, in theory, should be promoting healthier lifestyles.  And the problem is, I think, for many patients and for many doctors it becomes a complicated conversation that is wrapped up in -- you need to diet, not a terribly attractive word for some patients, and you also need to exercise, i.e., go buy a gym membership and start exercising in a way that is really foreign to many patients.  And so trials that have used diet and exercise in a trial design, meaning more than the average patient would do like the DPP, it worked.  It was the most beneficial at prevention of diabetes in the agents that were used in the DPP at least against metformin.  And it lowered the progression of impaired glucose tolerance to Type II diabetes by almost 60 percent over the three years of the study.  At about the same time and in the same journal -- The New England Journal from the same year -- a study was done in Scandinavia that basically showed the same thing -- that diet and exercise can be really effective. 

And then if you want to take the most extreme example that probably every doctor has seen -- a patient who has terrible diabetes who’s on every drug known to man, a lot of insulin, gets a gastric bypass.  They come back and see you six months or a year later, they’re 50, 100 or more pounds less and their diabetes drugs are gone or almost totally gone.  I mean, it’s kind of amazing.  So, we have lots of information to say that diet and exercise can work. 

We know the physiology and that it improves insulin sensitivity and actually improves cardiovascular risk profiles so it’s quote, unquote unloading the beta cell, which should be good for beta cells, and so all of that tells us it should be a great therapy and I think what’s lacking in our culture and most cultures around the world is finding ways to phrase that and put into practical interventions for patients so they are more effective at it.  One of the amazing things is people can actually do fairly modest dietary changes and fairly modest changes in their level of regular activity and really see large improvements in blood sugars.  It’s actually sort of amazing at times.  But we’re often just not articulate enough to try and help patients to design a program that they actually think they can participate in.