Diabetes is a metabolic disorder characterized by high serum glucose levels which result

from insulin resistance or deficiency. While it can be managed with exercise and dietary

modification, medication, especially insulin, is often required. An estimated 24 million

Americans have diabetes, or 8% of the population, and of these, 90% have type 2, or ‘acquired’

diabetes (Danaei et al., 2011). Because the Centers for Disease Control (CDC, 2015) has

classified diabetes as an epidemic – now prevalent not just in adult, but in children as well – it is

critical for both medical caregivers and laypersons to understand implications, symptoms, and

treatment vectors. The following work will explore a range of scholarly sources which examine a

range of factors pertinent to both diabetes researchers and clinicians, as well as those which are

intended for ‘broader’ consumption, as by the layperson or lay diabetic. Through use of the

National Library of Medicine tutorial on critiquing internet health information, this work will

show that lay sites often provide strong information, but their motives are suspect.

Scholarly Sources

Scholarly sources predominantly consider factors which contribute to the onset of

diabetes, and cause resistance to insulin, depriving cells of necessary nourishment, and causing

physiological damage through excess serum glucose levels. Information provided by the Centers

for Disease Control, for instance (2015) present such damage as causing pathological change to

the endothelial lining of blood vessels, and evidence to show that if diabetes is left untreated with

insulin, it may predispose the diabetic to an increased risk of cardiovascular disease, premature

disability or death (CDC, 2015). Though such information may well be of use to the lay patient,

they go into considerable detail with respect to the pathology of this condition, including factors

like increased liver production of glucose, impaired pancreatic function, cancer irradiation, and
autoimmune disease (CDC, 2015). Talukdar and Reddy (2017) focus upon “pancreatic exocrine

insufficiency” as it relates to Types 1 and 2 diabetes, and though their research has clinical

implications, including that “pancreatin supplementation could also have a positive effect on the

glycemic status of…diabetic patients,” it is a work of pure research with little relevance to the

lay patient (Talukdar & Reddy, 2017, p. 61, 69). Other scholarly studies explore the role which

Metformin (Fortamet) plays in the reduction of damaging glucose formation in Type 2 diabetics,

including Hundal et al. (2000), which found that this drug played a key role in a “a reduction in

[harmful] gluconeogenesis”, through inhibiting “pyruvate carboxylase-phosphoenolpyruvate

carboxykinase activity,” or possibly through the “increased conversion of pyruvate to alanine” in

the bloodstream (Hundal et al., 2000, p. 2068). Though Metformin has seen increased popularity

in recent years, these works’ stark scholarly tone would seem to exclude most lay patients.

Other scholarly sources which examine diabetes did so from a clinical perspective,

through analysis of patient compliance with insulin administration and other care regimes. For

instance, Currie et al. (2012) explain that many diabetes diagnoses are delayed for years due to

lack of demonstrable symptoms, and even once care is initiated, as many as 50% of diabetics fail

to fully comply with some or all aspects of their ordered care (Currie et al, 2012). From this

point, other studies explored causal vectors for such patient noncompliance, as linked to social

and behavioral issues, including patients’ feelings, thoughts, interpersonal relationships, and

culture or social class (Currie et al., 2012). Further barriers shown in scholarly studies include a

lack of education as to knowledge and skills required for treatment, improper health beliefs and

poor attitudes regarding the necessity of treatment, and the presence of environmental barriers to

adversely affect the ability of patients to perform self-care (Currie et al., 2012). Finally, social

isolation from or conflicts with family may also serve as barriers to diabetes management, as
well as psychological or psychiatric disorders including depression, anxiety, and eating disorders

(Salam & Siddiqui, 2014). Associated studies have highlighted the clinician-patient relationship

as one of the most important factors to bolster, if care compliance is to be improved (Sawyer &

Deines, 2013), especially as linked to the quality of this relationship, with superior outcomes

shown in patients who trust their physicians (and their advice) implicitly (Lowry et al., 2014).

Layperson Sources

Mitigating the effects of Type-2 diabetes, a disabling and life-shortening illness, are only

possible through deliberate care coordination by the patient and the clinician. Though patients

may take physicians’ advice on ‘face value,’ many often seek out their own information, and as

such, may turn to internet patient resources for guidance. Two sources informed this analysis of

‘lay’ diabetes informational resources: The first ‘lay’ source is WebMD, and while researchers

Semigran et al. (2015) showed that the popular ‘symptom checkers’ provided by this site – and

many others – had major “deficits in both triage and diagnosis,” and tended to provide advice

which was “generally risk averse,” and served to encourage “users to seek care for conditions

where self-care is reasonable,” this is not necessarily a negative with respect to WebMD’s

diabetes care advice (Semigran et al., 2015, p. 4). The WebMD site chosen, “Understanding

Diabetes -- Diagnosis and Treatment” (2018), is written in a format and in language which is

easily-understood, and defines both Type 1 and Type 2 diabetes, before outlining the various

tests that prospective diabetics may expect (including a fasting glucose test, oral glucose

tolerance testing, and A1c testing), and treatment methodologies. Critically, though WebMD

may encourage passive self-treatment for other conditions, this popular lay medical advice portal
is explicit in its treatment recommendations: “Diabetes is a serious disease,” it argues, “that you

cannot treat on your own,” and it recommends seeking physician advice (WebMD, 2018, p. 1).

The second ‘lay’ website, Dr. Axe: Food is Medicine, was chosen for its high search

placement on Google under the terms ‘natural diabetes cure‘. The ‘Dr. Axe’ site contains a host

of information about Types 1 and 2 diabetes, including the same CDC warning about diabetes

reaching ‘epidemic’ status in the U.S., before presenting a range of foods which prediabetics and

diabetics may incorporate or remove from their diets in order to slow their diabetic progression,

or to halt it altogether (Dr. Axe, 2018, p. 1). Dr. Axe recommends that prediabetics follow a

specific diet plan – one high in fiber, chromium, magnesium, and ‘clean’ protein – as well as

reduce their intake of refined sugar, grains, cow’s milk, and alcohol (Dr. Axe, p. 1). Though each

recommendation is supported by links to studies corroborating these claims, its prescribed meal

plan’s promise of reversing diabetes “naturally, in 30 days or less”, is suspect (p. 1).

Critique and Discussion

Using the template for lay criticism provided by the National Institutes of Health (2018),

both WebMD and ‘Dr. Axe’ can be considered reasonably reputable sources. Of these, WebMD

is the stronger of the two as a patient information resource. It maintains four core staff doctors,

and a team of 100 ancillary physicians upon whom they rely to ensure that their content is “up to

date, accurate, and helps you live a healthier life” (WebMD, 2018a, p. 1). Information provided

on this site is judged on the basis of its “relevance…clinical significance,” and “emerging health

trends,” and aside from advertising sales, does not appear to have any ulterior motives (WebMD,

2018b, p. 1). That said, its presentation and major promotion of a ‘symptom checker,’ a tool

which has been shown to reduce patient reliance upon expert care (and has been linked to the
greater promotion of potentially deleterious self-care) is questionable. Though this major health

information ‘portal’ – which is the 157th most-visited website in the U.S., and averages 148.6

million monthly unique visitors – is backed with links to peer-reviewed studies and other strong

information, its reliance upon advertising dollars means that it must attract visitors in order to be

profitable (Similar Web, 2018). To this end, while its diabetes information is sound, the site’s

overall impact upon lay information (as reflected in the Semigran et al. [2015] study) has been to

reduce reliance upon physician information in favor of internet resource-assisted self-diagnosis.

Dr. Axe, by contrast, offers a strong resource for diabetes information, albeit one which is

reduced by motives which seem linked to the titular physician’s line of health products. Though

Dr. Josh Axe is a “certified doctor of natural medicine, doctor of chiropractic and clinical

nutritionist,” and founder of a Nashville-based “functional medicine center,” hailed as one of the

world’s “most renowned” clinics, the site’s advice with respect to diabetes care appears to reflect

a ‘quick cure’ mentality (Dr. Axe, 2018a, p. 1). While this may be promising, such promises are

rarely useful for the diabetic patient. To the site’s credit, it includes a range of links to strong

clinical and scholarly works to support its claims. That said, its promotion of branded health

supplements for diabetes care, including chromium picolinate, cinnamon, and bitter melon

extract, are backed by studies which consider the impact of such supplements among patients

who already have strong glycemic control, meaning that their efficacy as a diabetes ‘cure’ is low.

Finally, the site promises that following the dietary plan it lays out – to the apparent exclusion of

physician recommendations – will lead to the reversal of diabetes symptoms, and the need for

insulin, within thirty days. Especially as backed by prompts to purchase branded supplements

from the Dr. Axe online store, this promise is self-interested, disingenuous, and dangerous.
 Scholarly sources tend to be focused upon clinicians or researchers, so their technical

findings are often of little use to the lay diabetic. The online sources considered, by contrast, tend

to provide some useful information, but such information is offered in an environment whose net

effect is one of either promoting ‘self’-reliance upon potential diabetics (though WebMD is

explicit in arguing for the importance of physician advice), or appears to be designed to push

customers toward purchasing branded supplements and other products. In any case, the best

option for diabetics is to seek out their physician’s advice, and then follow it to the letter.
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Danaei, G., Finucane, M.M., Lu, Y., Singh, G. M., Cowan, M.J., Paciorek, C.J., & Rao, M.

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