Do Type 2 Diabetes Patients Always Deteriorate?

[Enchantress]

Do Patients with Type 2 Diabetes Always Deteriorate?

The Toxic Myth that Kills and Cripples People with Type 2 Diabetes

The belief that science has proven, beyond a doubt, that no matter what you do your type 2 diabetes will get worse is the single most dangerous idea you are likely to encounter as you begin your struggle to live a healthy life with diabetes.

Unfortunately, your doctor probably believes it, and though he may give lip service to the idea that you can control your disease through diet, exercise, and drugs, his real belief is likely to be that nothing you can do will make much difference in your long-term outcome. That being the case, he is not likely to urge you to take a proactive approach to managing your disease but will merely write you prescriptions for drugs that at best do a mediocre job of controlling your blood sugars.

Why doctors believe this toxic myth
They've Seen it in their Practice
Doctors will tell you that they've treated lots of patients with type 2 diabetes and that few if any of their patients can control their diabetes with diet, that they don't lose weight, and that even with good control they end up with complications.

UKPDS "Proved" People with Good Control Deteriorate
Doctors will also tell you that a large-scale study, the UKPDS (United Kingdom Prospective Diabetes Study) proved that even with good control patients with Type 2 diabetes inevitably deteriorated over time. UKPDS, they'll tell you, found that the Hba1c test results of patients with good control gradually worsened every year. Not only that, but many doctors also believe, though they may not tell this to patients, that while good control did make a small difference in the rate of complications, that difference was too small and far too many people with good control got complications.

I didn't make this last bit up. You can read it in the words of Dr. Roy Taylor, a professor of medicine and metabolism at the University of Newcastle upon Tyne in a slide presentation he gave to other medical specialists. This talk was presented by the Annenberg Center for Health Sciences and published by Medscape December 22, 2003 as an online course offering good for earning one continuing medical education (CME) credit. Read it HERE.

In his presentation, Dr. Taylor points to a chart taken from UKPDS data titled "Newly Diagnosed Type 2 Diabetic Subjects Showing Progression of Retinopathy" and explains, "These data are usually presented as showing a wonderful difference between the groups, [those controlling their blood sugar and those not] 37% relative risk reduction. But take another look. This slope is unfortunate. This slope is almost equally unfortunate for the individuals concerned. Although intensive therapy in type 2 diabetes over 15 years makes a difference, it's not a staggering difference."

Later discussing what the UKPDS findings were about the progression of nerve damage he says "the abnormal nerve function continues to progress inexorably"

When discussing early signs of kidney damage, he delivers the same message. "Intensive therapy [i.e. blood sugar control] does not seem to be able to stop this."

So it is no surprise when Doctor Taylor concludes that controlling blood sugar in type 2 diabetes may make a small difference "but not such a huge difference that you would want to go out of your way as a patient to achieve it, perhaps, if you were shown this graph and told that over 15 years of intensive therapy you would be not much different compared with a "laissez faire" approach."

Abandon Hope All Ye Who Enter Here?
If Dr.Taylor is right, it would make sense to take a fatalistic attitude towards your diabetes. If If a diagnosis of diabetes sentences you to a life haunted by nasty complications and premature death why put yourself through all the miseries of a life-long diet and the struggle to watch what you eat every day? If there is nothing you can do, it is rational behavior to shift your energy elsewhere and enjoy life--including the foods you love--while you can. But it is not true. Doctor Taylor and his peers have missed one extremely important point in considering the UKPDS data.

"Good Control" in UKPDS and Common Medical Practice is Really Mediocre Control
Though doctors do in fact see patients with what they consider to be "good control" go on to develop complications, and though it is true that the UKPDS did show that patients with "good control" deteriorated over time, "good control" in UKPDS and in most medical practices is defined only to mean that patients registered Hba1c test values under 7.0%.

The Hba1c test value of 7.0% which doctors and UKPDS have defined as "good control" for people with Type 2 diabetes, is the test value which turns out to correspond to an average blood sugar of 172 mg/dl (9.6 mmol/L).

This blood sugar level is considerably higher than the level at which neuropathy begins and at which lab research has shown that irreversible beta cell damage occurs--which you'll remember was 140 mg/dl (7.8 mmol/L).

UKPDS Participants were Probably Spiking Way Above 200 mg/dl (11 mmol/L)
But even more important, the HbA1c test result reflects the average blood sugar sustained over the past several months. And because it is an average, it does not distinguish between the person whose average blood sugar level of 172 mg/dl was achieved by maintaining their blood sugar at a steady 172 mg/dl throughout the day and the person whose blood sugar surged up to 300 mg/dl after eating high carbohydrate meals and then plummeted to 70 mg/dl as insulin kicked in, insulin that was injected or stimulated by the sulfonylurea drugs that force the beta-cells to produce more insulin.

It is very likely that for the UKPDS participants and for most of your doctors' patients who have been following the standard dietician advice to eat a high carbohydrate, low fat diet, the latter was what was happening--they spent hours with blood sugars over 300 mg/dl which were balanced by d periods of insulin-stimulated low blood sugar. The participants in the UKPDS were using sulfonylurea drugs and insulin to achieve their blood sugar targets. The standard dietary advice given to patients on insulin and sulfonylurea drugs is to eat a very high carbohydrate diet, in order to avoid the very real possibility of dangerous and even fatal episodes of hypoglycemia which result when their insulin is much higher than the corresponding levels of blood sugar. So the chances are extremely good that the patients in the UKPDS did have blood sugar that was rollercoastering up and down all day.

So when all is said and done, what UKPDS really tells us is that patients on drug regimens that allow their blood sugars to rise high enough to produce glucotoxicity for many hours each day will continue to experience complications. And that these patients will also see their blood sugar control deteriorate over time as their remaining beta cells succumb to glucotoxicity.

Think of it this way, would you believe your doctor if he said that most patients who quit smoking develop lung cancer if he defined "quit smoking" as "Smoke only 10 cigarettes a day?"
That's exactly the same thing going on here, because the blood sugar targets doctors are studying are way over the level where good research has proven beta cells and organs are irreparably damaged. (For more on this subject read At What Blood Sugar Levels Does Damage Occur

The Hba1c that Corresponds to Truly Normal Blood Sugar Levels
The blood sugar level that corresponds to what truly normal people experience is under 5.0%. Another study, EPIC-Norfolk, found that the risk of death from heart attack for all people, not just those with diabetes was half as much when Hba1c test results were below 5.0% than when they were above it. However, the risk of all other diabetic complications remains very low as long as the Hba1c remains under 6.0%, which is the range most labs assign to "normal."

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[Enchantress]

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Another Less-Known Study Contradicts UKPDS
As we mentioned earlier, the Hba1c is only an average. It ignores the very important question of how high blood sugars are spiking after meals. So what happens if instead of measuring only the HbA1c, you measure post-meal blood sugars and attempt to control how high they go?

A ground-breaking Japanese study answers this question definitively. The researchers in this study, conducted in Kumamoto Japan, found that by using post-meal blood sugar targets, they were able to keep the Hba1cs of participants in their study stable over its entire 6 year course. Instead of the "inevitable decline" in blood sugar control we saw in the UKPDS, these people with type 2 diabetes saw no deterioration at all.

Not only that, but over the course of the study, the incidence of retinopathy, kidney damage, and nerve damage, were dramatically lower in the group that maintained tight control of their post-meal blood sugars. In fact, the intensive intervention group as a whole saw slight improvements in the qualities of their nerve damage by the end of the study rather than the deterioration seen in all other studies.

Motoaki Shichiri, Hideki Kishikawa, Yasuo Ohkubo, , Nakayasu Wake, Long-Term Results of the Kumamoto Study on Optimal diabetes Control in Type 2 Diabetic Patients. Diabetes Care Volume 23 Supplement 2, 2000 www.findarticles.com/p/artic..._23/ai_62086006

What makes this study so interesting is that the average HbA1c test results of the people in the Kumamoto "intensive intervention group" was identical to the average HbA1c of the people in the UKPDS at the beginning of the study. What was different was that the blood sugar control strategy the Kumamoto study used focussed on keeping post meal blood sugars lower.

This is extremely good news for people who do not wish to succumb to inevitable decline. And, in fact, it is even better news than the forgoing would suggest, because the patients in the Kumamoto study were controlling their blood sugar using an intensive insulin regimen which required that they keep their blood sugars higher than normal to avoid the danger of severe low blood sugars. So the people in the "intensive intervention" group whose results were so impressive compared to the "intensive intervention" group in the UKPDS still had HbA1cs near 7.0% and post meal blood sugars that rose to 180 mg/dl after meals.

What if you Keep Post-Meal Blood Sugar Spikes Below 140 mg/dl?
Just keeping blood sugar from spiking over 180 mg/dl made a huge difference in the incidence of complications and even improved neuropathy. But we know that neuropathy starts when blood sugars pike over 140 mg/dl. So the question that is still unanswered by this study is this: what would happen to people with type 2 diabetes who were able to keep their blood sugars under 140 mg/dl--the level at which it is believed that serious damage begins?

Unfortunately, you won't find a study that answers this question because most doctors believe that it is impossible for people with type 2 diabetes to achieve that level of control.

And it is impossible if patients attempt it while eating a high carbohydrate diet. But plenty of people online who a follow a lower carbohydrate diet have found that they are able to prevent their post-meal blood sugars from rising over 140 mg/dl, without injecting any insulin.

The Key is the Strategy Known as "Eating to Your Meter"
The way that people with type 2 diabetes are able to reach truly good control is described here: http://www.alt-support-diabetes.org...0Diagnosed.htm. This strategy has worked for many people whose Hba1cs were as high as 13.0% at diagnosis who were able to bring them down to the 5% range within a few months. I've maintained an Hba1c in the 5% range for most of the past 6 years.

Some people can achieve this level of control with dietary control alone. Others find that it helps to take Metformin and/or Avandia/Actos. Most people who pursue this strategy avoid the sulfonylurea drugs because they force the pancreas to overproduce insulin which can cause dangerous low blood sugar attacks. Metformin and Avandia/Actos usually do not cause lows.

Where are the Studies of Long-Term Consequences of Truly Good Control?
There are none. To date there is no study of people with type 2 diabetes who have consistently achieved post-meal blood sugar levels under 140 mg/dl. In fact, most studies besides the Kumamoto study have completely ignored the question of what post-meal values participants achieved.

Because we only have studies that show that patients who maintain blood sugars in the toxic range well above 140 mg/dl (and who spike over 200 mg/dl daily) inevitably deteriorate it is premature to conclude that all patients with type 2 diabetes inevitably deteriorate.

Don't Settle for Mediocrity No Matter What Your Doctor Advises
Doctors have indeed seen thousands of patients with type 2 diabetes fail to lose weight--because they put them on low fat/high carbohydrate diets that don't work for people with diabetes. They've seen them develop complications with good control, only because "good control" meant spiking over 200 mg/dl after every high carbohydrate meal.

But in the past couple years since low carb dieting became more popular, doctors are also seeing a new kind of patient, the patient who loses a lot of weight with a low carb diet and in the process attains hitherto unbelievable blood sugar control--while bringing down cardiac risk factors like high cholesterol and blood pressure. Studies are only now beginning on the long-term health impact of these changes. Unfortunately, it will take a decade or more until the results are in.

If you pursue a lowered carbohydrate, "Eat to your Meter", regimen and keep your blood sugars under 140 mg/dl at all times, and a decade hence studies show that even with excellent control and normal blood sugar levels patients still deteriorate, all that you'll have lost is a lot of carby meals (and possibly some weight.). But if you isettle for that 7.0% Hba1c control your doctor recommends, with its post-meal spikes over 200 mg/dl, and in 10 years the studies show that keeping blood sugar under 140 mg/dl at all times prevents most diabetic complications, you may have paid for your choice with bleeding retinas, failing kidneys, and gangrenous toes.

Which approach you choose is up to you, but remember, it's not your doctor's retina, kidneys, and toes that are at risk here.

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