Wednesday, February 19, 2020

Retrospective #368: My 2-Month, 20-Pound Challenge

At the beginning of February 2017, I was in a unique situation. It was of my own making, and it was an opportunity to take sole responsibility for my actions. There were no confounding factors (“excuses”) or impediments to my success (or failure). It was a good test of my intentions and my integrity in taking responsibility for whichever outcome.
The circumstance: I was “home alone” for 2 months. After driving my wife to Florida after Christmas, I flew to Bogotá, Colombia, for 3 weeks to study Spanish. While there I got help translating my 16-page “Folleto” on the cause of Type 2 Diabetes and how to treat it as a dietary disease. I then flew to Aruba to join my wife at our time share for our 25th wedding anniversary, then home to New York for the winter. A week in the hot sun was more than enough for me.
So, to fulfill a commitment I had previously made to Megan Ramos (part of my “integrity test”), the Intensive Dietary Management Program Director and Clinical Educator in Jason Fung’s office in Toronto, and a Facebook friend, I decided to fast for 2 days a week. I selected Tuesdays and Thursdays. On those days I will only take a 16-oz coffee in the morning with stevia and full ounce of heavy cream; then, at night, 1 wine spritzer. Nothing else until the next day. I know this will not be difficult for me because I am not hungry. I am already sufficiently keto-adapted for my body to switch easily from whatever I eat (very-low-carb) to fat-burning to maintain energy balance and a high metabolic rate.
So, I am now cooking for myself. This is something, guys, that will teach you how much you under appreciate that your spouse cooks for you every day, as mine does. Thus, on the remaining 5 days, I will cook supper twice, each time preparing food for 2 days. On the 5th day – once a week – I will go out to dinner. That day may vary each week.
On non-fasting days, I will take the same coffee in the morning. Then, if I feel a “need” to eat something before supper, I have some cans (“tins”) in the pantry: 1) Brisling sardines in EVOO and 2) kippered herring in brine, both of which I love. The sardines, due to the fat (EVOO), are a meal in themselves. The herring, in brine, is more like a snack, but plenty since I will not be hungry. I will use them as a light or late lunch, should I decide to eat something. I will also keep on hand a few hard-boiled eggs from a local farmer if I feel the need for them, sort of like a security blanket.
Then for supper, my main dish will mostly be stove-top preparations of various cod recipes I have, or a veal stew. The cod is wild caught in the North Atlantic and flash-frozen at sea. My recipes incorporate vegetables like onions, celery, cauliflower and fennel. I cook in coconut oil, butter or olive oil and add garlic, green olives, red pepper flakes, sometimes petite cubed canned tomatoes and always lots of salt and fresh ground black pepper.  As an alternate meal, I will sometimes make a veal kidney dish or “tripa en salsa roja,” a Spanish preparation called “callos.”
The veal is from another local farmer. For the stew, I use bacon, mushrooms, and onions and brown the veal cubes in coconut oil before baking. For the kidney dish, I add mushrooms, onions and Marsala wine.  With each of these supper meals, I will drink 2 red-wine spritzers. My house wine is a Spanish Rioja called El Coto.
Just to be clear about this: On my 5 non-fasting days each week, I will take only morning coffee, an occasional “big” lunch (a 3.75 oz. can of sardines + EVOO) or a “light” lunch ( a 3.5 oz can of kippered herring in brine) and the occasional hard-boiled egg or two. Then, supper with 2 wine spritzers. The nutrient breakdown is this:
Fasting days: Calories: 225kcal; Fat: 11g; Pro: 1g; Carbs: 4.75g; Alcohol: 15g
Non-fasting: Calories: 1000-1200kcal; Fat: 45-70g; Pro: 45-85g; Carbs: 15-30g; Alcohol: 30g 
I originally wrote this on Super Bowl Sunday 2017 at 248 pounds (FBG: 104mg/dl). I started the next morning. This “manifesto” was first published on February 19, 2017, three years ago today.
Result (spoiler alert): I lost 31 pounds in 10 weeks, fasting 2 days a week and cooking for myself. My FBG average dropped from 119mg/dl before to 81mg/dl (10-week average). A1c went from 5.8% to 5.3%. Lipid Panel: Total Cholesterol: 201mg/dl; HDL: 74mg/dl; LDL: 114mg/dl; Triglycerides: 67mg/dl. My weight today (3 years later) is 225lbs, plus 8 lbs. in 3 years. I still fast from time to time, sometimes alternate day, sometimes consecutive day. It’s easy when you’re not hungry.

Tuesday, February 18, 2020

Retrospective #367: My Arm’s Length Perspective from Colombia

In February 2016, as I prepared to leave Bogotá, Colombia, after 3 weeks of studying Spanish, a few thoughts related to type 2 diabetes came to mind. Bogotá is a burgeoning city, growing leaps and bounds, transitioning from “a feudal society” (to quote the husband of my teacher) to a modern, invigorating, stimulating place. I loved it, and it’s exciting to see the changes coming about, but also shocking to see the stark contrasts. For grounding and perspective, the husband reminded me that women only gained the right to vote in 1957.
For me personally the most surprising discovery was that the brand new, modern apartment I rented, that had multiple USB connections in every room, has no central heat! Further, there is no hot water in the kitchen – only in the bathroom, supplied by an electric in-line hot water heater for the sink and shower.
At first, I thought that this was a factor of the neighborhood (services are taxed by “estrado”). This method of taxing services by socio-economic status is designed to give preference (“subsidies”) to the less advantaged. Unfortunately, it also results in stagnation and immobility by stigmatizing the poorer neighborhoods.
Later, I discovered that the modern, well-designed apartment of my teacher and her husband (both PhD’s teaching at the National University) also has no central heating and no hot water in the kitchen. ¡Qué sorpresa! They live in an upscale neighborhood in the northern reaches of the city. The “no heat” explanation relates in part to the climate. Bogotá has a moderate climate year-round. It is located close to the equator but at a very high elevation (8,675 feet or 2,644 meters), so temperatures are constant all year round. It never snows.
So this partially explains the central heating issue, but not the lack of kitchen hot water. “How do you wash dishes,” I asked the husband as he did them. “I scrub them well,” he said.  Does that give you perspective?
Type 2 diabetes is similarly just emerging from the dark ages. One hundred and fifty years ago type 2 diabetes was understood as a dietary disease (see Retrospective #1 re: French physiologist Claude Bernard and English undertaker William Banting). It was known as a disease of excessive consumption of carbohydrates and was treated by reducing carbohydrates in the diet. Then, in 1921, Frederick Banting (bizarrely, a distant relation!) discovered how to make insulin in the lab, and since then type 2 diabetes has been treated like type 1 diabetes, a disease of too little insulin.
When our insulin receptor cells resist the uptake of glucose, i.e. they express Insulin Resistance (IR), the pancreas produces more insulin until it eventually wears out. Doctors hasten this catastrophic failure of the pancreas by adding pharmaceuticals, like sulfonylureas (Micronase, glyburide, glipizide, et al.) to push the pancreas to exhaustion. Then, the doctors add injected insulin to the patient’s regimen. This medieval practice, not unlike “bleeding the patient,” is still the Standard of Care of the medical establishment and their government overseers in the United States.
Until recently. We are finally beginning to see a Renaissance. Increasingly type 2 diabetes is being understood again as a disease of Insulin Resistance, resulting in too much insulin. The goal in treating type 2 diabetes should be not only to lower the glucose level in the blood (by diet instead of drugs), but also to lower the insulin level in the blood.
This will occur, and will only occur, when the glucose level lowers, because that is how the body “knows” that it needs to begin to burn fat for fuel (triglycerides, in the form of body fat stored around the “trunk,”) to maintain energy balance and a fully active metabolism. The body, including heart and brain, loves these fatty acids and the ketone bodies that are produced as a side effect of lipolysis (the break-down of triglycerides to fatty acids).
Bogotá is rapidly transforming itself. ¡Ojalá que el mundo de los diabéticos se haga lo mismo! Y pronto.

Monday, February 17, 2020

Retrospective #366: Academy of Nutrition and Dietetics, a Secret Society

Surfing the web a while ago, I came across the Academy of Nutrition and Dietetics (AND). It turns out that for almost 100 years, until 2012, this organization was named the American Dietetic Association, unfortunately sharing the same acronym with the more recognized American Diabetes Association. With my interest piqued, and having a long-time interest in the subject of nutrition, I delved into the membership categories. Here’s where I bumped into my first road block: membership is restricted to only RDNs and other dietetics’ professionals.
Still, being interested in their message, I clicked on their “Advocacy” tab, then “Disease Treatment and Prevention” and finally “Diabetes Prevention Legislation.” I was pleased to see that the AND “has been actively involved in developing and generating support for five pieces of legislation that would help prevent type 2 diabetes.” Great, I thought, let’s have a look. Unfortunately, that was not possible. To see more I was told to “log-in or join.” But, as I am not eligible to join, and therefore can’t log in, the legislation for which they advocate will have to remain secret legislation. Only members of the Academy are eligible to view legislation they advocate to “prevent type 2 diabetes.”
So, I went to Wikipedia. I knew of course that many Wiki sites are written by the searched organization, but I thought I might learn something more about AND, as I would never be eligible to join. Here’s what I learned:
     The Academy "maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise."
     The Academy opposed mandated labeling of "trans fats" on food packaging.
     The Academy has given low ratings to the “high-protein, low-carb” diet known as the Atkins Diet, insisting that the diet is "unhealthy and the weight loss is temporary."
     The Academy maintains that carbohydrates are not responsible for weight gain any more than other calories.
Okay, I no longer needed to see the five pieces of legislation that AND has developed. I know where they’re coming from. But why? What motivates them to be so obtuse? And so backward? I needed to look further into AND.
Here’s what Wikipedia says: “To help better communications with the US government, the Academy of Nutrition and Dietetics has offices in Washington, DC. They also operate their own political action committee. The Academy spent $5.8 million lobbying at the state and national level from 2000–2010.
And “A 1985 report noted the Academy has supported licensing for dispensing nutritional advice,” and “In addition… [has] support[ed] legislation regulating the professional nutrition field in [various] states.”
And finally, the coup de grace: “A 1995 report noted the Academy received funding from companies like McDonald’s, PepsiCo, The Coca-Cola Company, Sara Lee, Abbott Nutrition, General Mills, Kellogg’s, Mars, McNeil Nutritionals, SOYJOY, Truvia, Unilever, and The Sugar Association as corporate sponsorships.
“The Academy also partners with ConAgra Foods, which produces Orville Redenbacher, Slim Jims, Hunt’s Ketchup, SnackPacks, and Hebrew National hot dogs, to maintain the American Dietetic Association/ConAgra Foods, ‘Home Food Safety...It's in Your Hands’ program.” Additionally, “the Academy earns revenue from corporations by selling space at its booth during conventions, doing this for soft drinks and candy makers.”
Wikipedia continues with this trenchant comment from nutrition expert Marion Nestle. She “opined that she believed that as long as the AND partners with the makers of food and beverage products, ‘Its opinions about diet and health will never be believed [to be] independent.’” And, “Public health lawyer Michele Simon, who researches and writes about the food industry and food politics, has voiced similar concerns stating, ‘AND [is] deeply embedded with the food industry, and often communicate[s] messaging that is industry friendly.’"
I guess it’s a good thing for both of us (AND and me) that they won’t let me join their corrupt organization. I would just “rock the boat” or, to use a more apt but mixed metaphor, upset the rotten apple cart.

Sunday, February 16, 2020

Retrospective #365: Look at what’s happening to Medicare!

A 2016 article in the Journal of the American Board of Family Medicine begins, “Clinical practice guidelines abound. The recommendations contained in these guidelines are used not only to make decisions about the care of individual patients but also as practice standards to rate physician ‘quality.’” Did you know that? I have for awhile, and it concerns me. I first became aware of it during the funding cuts in Medicare (+/- $750 billion) during the “negotiations” leading up to the passage of the “Affordable Care Act” or ACA, aka Obamacare.
The Journal article continues, “Thus there is an inevitable aspect of guideline development that makes it subject to value judgments and can be unconsciously colored by intellectual, professional, or financial conflicts of interest.” These include biases such as “decisions colored by tunnel vision (job conditioning), ‘seeing what you want to see’ (confirmation bias), decisions limited to the tools at hand (Maslow’s hammer), or other inclinations that can affect judgment.” That last one especially concerns me. Why? Medicare Payment Reform.
We have all become aware of the movement towards Electronic Health Records (EHR). But did you know that there are financial incentives and disincentives for physician compliance? The EHR program, called Meaningful Use (MU), is now in the process of being itself re-reformed. According to a blog post from Impact Advisors, posted before the final rule was issued, “providers simply wanted to ‘check the box’ in order to reach MU thresholds (and thus avoid ‘adjustments,’ i.e., penalties, foregoing the larger opportunity to improve care.”
EHR was Part 1 of a larger reform program of the Center for Medicare and Medicaid Services (CMS). It is still in place, but Part 2, described as “share data” and Part 3, “improve outcomes,” are now part of a new Medicare Payment program designed to overcome the “noted weaknesses of MU.” Part 1 will be transformed and phased in by stages starting in 2017. Parts 2 and 3, now the Merit-Based Incentive Payment System (MIPS), is part of the Medicare Access and CHIP Reauthorization Act (MACRA) and implementation began in 2019.
Now, according to an AMA email “alert” that I received last fall, CMS has issued its final MACRA rule, detailing the new Merit-Based Incentive Payment System, now called the Quality Payment Program (QPP). In the email, AMA President Andrew Gurman thanked then CMS Acting Administrator Andrew Slavitt for being a “sincere partner” during the process. Gurman was very pleased at the influence the AMA’s comments had that “will allow for a reasonably paced progression into the program so that physicians can learn and adjust…”
He said, “The key elements of the proposed rule that CMS changed based on our recommendations are:”
     Physicians would not have to report in all four MIPS categories to avoid a negative payment adjustment. Instead, the only physicians who “will experience a negative 4% penalty in 2019 [increasing in steps to 9% by 2022] will be those who choose to report no data.”
     Participating in one of 4 options under “Pick Your Pace” will “help the physician avoid penalties.” At the very least if (s)he “chooses to report for only one patient on just one quality measure, one improvement activity, or the 4 required Advancing Care information measures, [(s)he] will avoid a negative payment adjustment.”
     The final rule established a 90-day reporting period, “a significant change over the proposed rule, full calendar-year requirement.” If the physician reports for at least 90 continuous days in 2017, (s)he will be eligible for a positive payment adjustment. This adjustment allows the physician to start later, to have more time to prepare.
     A reduction in the program-wide reporting burden from 11 reporting measures to 4 in 2017 and 5 thereafter.
     “An increase in the low-volume threshold to qualify for exemption from QPP participation.” CMS increased the threshold from $10k to $30k in Medicare payments, but kept the 100 Medicare patients per year limitation. So, your physician has been incentivized to not accept new Medicare patients, and to drop the old ones.
Does this give you a sense of why your relationship with your doctor has changed in recent years? I started this column feeling a bit angry at my doctor. I end it feeling sorry for him. Look what’s happening to Medicare! 

Saturday, February 15, 2020

Retrospective #364: “Prediabetes, in other words, is Diabetes”

This title is in quotes because…I think I cribbed it from Kelley Pounds, an RN, CDE, blogger and diabetes educator whose writings I always find interesting and informative. But, alas, I can’t find that title in her Table of Contents. So, a hat tip to Kelley Pounds. Check out her home page.
The point of the title is that Kelley, and I and many other “activists,” and of late, even some researchers, are urging the public health establishment in the U. S. and world-wide to take a hard look at the current Clinical Guidelines for defining Prediabetes and consider lowering or re-defining it. The implications of doing this are momentous; but likewise, if this is not done, the outcomes will be catastrophic. Consider this December 2016 revelation from the CDC: “Life expectancy for the U. S. population in 2015 was 78.8 years, a decrease of 0.1 years from 2014.” That’s the first DECREASE IN LIFE EXPECTANCY in the U.S. since 1999. Think it’s related to our lifestyle? To our diet?
A ton of evidence associates LIFESTYLE DISEASES with METABOLIC SYNDROME, the major outcomes of which are obesity, Type 2 Diabetes and heart disease. That’s why a Better Standard of Care is needed to address this scourge.
Cardiovascular Disease (CVD), Coronary Heart Disease (CHD), Stroke, Type 2 Diabetes Mellitus (T2DM), Non-alcoholic Fatty Liver Disease (NAFLD), Alzheimer’s Disease, aka Type 3 Diabetes, and even Erectile Dysfunction, plus several types of cancer; A large population study in July 2010 in “Diabetes Care,” shows that “the relative risks of various cancers imparted by diabetes are greatest (about twofold or higher) for cancers of the liver, pancreas, and endometrium, and lesser (about 1.2–1.5 fold) for cancers of the colon and rectum, breast, and bladder.”
A WebMD stub puts it succinctly: “Metabolic syndrome is a collection of symptoms that can lead to diabetes and heart disease. The good news is that metabolic syndrome can be controlled, largely with changes to your lifestyle.” The five related symptoms, first introduced nine years ago to my readers in Retrospective #9, and updated in Retrospectives #78, #334 and #335 are: a Body Mass Index (BMI) ≥30, or large waist circumference (men ≥40 inches, women ≥35 inches); elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, and/or use of medications for hypertension) and elevated fasting glucose (≥100 mg/dl, and/or the use of medications for hyperglycemia).
In the U.S. the longstanding criteria for a clinical diagnosis of Type 2 Diabetes Mellitus (T2DM) was two consecutive office visits with a fasting blood sugar ≥140mg/dl (7.8mmol/L). In 1997 that standard was lowered to ≥126mg/dl (7.0mmol/L). In 2002 a definition for Pre-Diabetes was added: an IFG ≥ 100 to 125mg/dl (5.6 to 6.9mmol/L) or an IGT of 140 to 199mg/dl (7.8 to 11.0 mmol/L) two hours after a 75-gram glucose challenge. The WHO uses a higher IFG threshold: ≥110to 125mg/dl (6.1 to 6.9mmol/L).
Later, in the U. S., the HbA1c measurement was added to supplement or in some cases now to supplant the IFG. In the U. S., an HbA1c between 5.7% and 6.4% is considered Pre-Diabetic and ≥6.5% Type 2 Diabetes. Elsewhere in the world, Pre-Diabetes is defined as an “A1c” ratio between 49 and 56mmol/mol and Type 2 Diabetes as ≥58mmol/mol.
For years leading research scientists like Ralph A. DeFronzo and pioneering clinicians like Richard K. Bernstein have called for a lower standard for the diagnosis of incipient Type 2 Diabetes. These men are leading diabetes specialists who have devoted their lives to combating this disease. They are both superstars.
Now, as I reported in #362, the BMJ (British Medical Journal) has published IN 2016 a Chinese meta-analysis done on 1,611,339 people. The lead researcher’s takeaway: “Effective intervention in prediabetes is not just for prevention of diabetes, but also cardiovascular diseases.” The majordomos are starting to connect the dots.
Type 2 Diabetes has to be redefined, as Kelly Pounds and I and DeFronzo and Bernstein would say – indeed have said: “PREDIABETES, IN OTHER WORDS, IS TYPE 2 DIABETES.”
And at the clinical level today, physicians have to revise their Standard of Care and not treat Prediabetes with temporizing measures, e.g., “We’ll have to monitor your blood sugar” (read: to watch your Insulin Resistance worsen as you continue to eat the Standard American Diet. Clinicians need to tell you: “If you are Prediabetic, you are in fact Diabetic. You have Insulin Resistance. You need to change your diet. You are Carbohydrate Intolerant.”

Friday, February 14, 2020

Retrospective #363: Type 2 Diabetes, a Lifestyle Disease

Okay, so which is it? A Dietary Disease or a Lifestyle Disease? It’s both, of course; diet is a part of Lifestyle. But why then is Establishment Medicine comfortable with calling it a Lifestyle Disease and not a Dietary Disease? They would tell you that lifestyle includes such things as doing 175 minutes of exercise a week (which while good for your health, is not necessary) and giving up smoking (which while also good, isn’t relevant to diabetes). Forget the epidemiological studies that show a correlation with Type 2 Diabetes. But remember, “Correlation does not imply causation.”
Exercise is a great habit to have. It builds muscle, keeps you fit, and if you’re a Type 2 or even Prediabetic, it improves your insulin sensitivity. But it’s not necessary to treat Type 2 diabetes. Eating fewer carbs, and thereby secreting less insulin, also improves your insulin sensitivity. “Insulin causes Insulin Resistance,” as Dr. Jason Fung recently blogged.
No, Establishment Medicine probably doesn’t want to call Type 2 a Dietary Disease for a number of reasons:
1)  Some clinicians simply don’t know. I know that’s hard to believe, but I’m afraid it’s true. It’s called “tunnel vision.” See Retrospective #365, “The Dual Pincers of Clinical Practice Guidelines,” this Sunday, for a full explanation.
2)  If you understood that Type 2 Diabetes and Prediabetes are Dietary Diseases, then the logical “treatment” would be a changed diet, not pills and injections… and you could still advocate for exercise and secession of smoking. Ah, but then it would be a less persuasive and perhaps a less effective argument if it was not linked to the avoidance of Type 2 Diabetes. And, if you didn’t have a prescription to write, the patient would feel “cheated.” The patient wants you, oh omnipotent dispenser of scripts, to “cure” this pernicious disease for them.
3)  If Type 2 Diabetes and Prediabetes are acknowledged to be Dietary Diseases, caused by the dietary advice that Government Dictocrats have mandated and the Medical Establishment has peddled for the last 60 years, then your doctor, if he or she were to tell you to change your diet to almost the exact polar opposite of what he or she has been telling you to eat over these many years, they would look pretty silly or just stupid. And the general public, and your doc’s patients in particular, would lose confidence in these omniscient demigods. They’d lose patients too.
4)  The ADA used to say that low carb diets were not safe. Then, the evidence from controlled trials proved them wrong. Then they said they were safe for a limited time only; then the evidence proved that wrong too. Then they said – actually, they’ve said all along – that low carb diets were too difficult to follow. That’s true for some, but certainly not true for many others. Others found them easier to follow than a low-fat, calorie- restricted, “balanced” diet because weight loss, without hunger, was possible. In fact, it was easy. And followers of low-carb, high- fat diets, besides keeping the weight off, had better glucose control and better lipid (cholesterol) profiles!
No, it’s easier to see the patient, take a blood sample, and then tell them (in a phone call or a note with your lab test) that, “Your sugar is a little high; we’ll have to monitor that.” And when you continue to eat the same prescribed “balanced” diet, and exercise as you were told, and your blood sugar goes higher still, the doctor will tell you, as Tom Hanks related to David Letterman in Retrospective #160, “You’ve graduated; you’re now a Type 2 Diabetic.”
Well, what did you expect? You continued to do the same thing and yet you expected a different result? Type 2 Diabetes is a Progressive Disease. Insulin Resistance is a Progressive Condition. Insulin Resistance = Type 2 Diabetes. Insulin Resistance = Carbohydrate Intolerance. The only effective treatment for a Dietary Disease is a different diet.
The only effective treatment of Type 2 Diabetes is a Low Carbohydrate Diet. Not “watching your blood sugar” as it progressively worsens. Not treating this symptom – an elevated blood sugar – with a drug that will force your pancreas to secrete more insulin and thus eventually wear out and die.
Type 1 Diabetes is a disease of too little insulin. Type 2 Diabetes is a disease of too much insulin. The best way to treat your pancreas, and thus save it, is give it a break! Let it secrete less insulin. Eat a low carb diet!

Thursday, February 13, 2020

Retrospective #362:A Stricter Prediabetes Definition

In 2016 a Reuters Health Information article in Medscape Medical News headlined, “Meta-Analysis Backs Stricter Prediabetes Definition.” It reports on a new study in the BMJ (British Medical Journal) that “people with a fasting glucose as low as 100mg/dl (5.6mmol/L) are at increased risk of cardiovascular disease.” It also showed increased CVD risk in individuals with an HbA1c as low as 5.7% (39 mmol/mol). What is significant about this Chinese study is that it is very large (53 studies, comprising 1,611,339 people). The big takeaway: “Effective intervention in prediabetes is not just for prevention of diabetes, but also cardiovascular diseases.”
This isn’t news to my regular readers. I have been saying it forever, most recently in the risk analysis presented in Retrospective #345, “How Diabetic Do You Want to Be? (Part 2). That column was based on the laudatory work of Jenny Ruhl at her website, Blood Sugar 101. Jenny has meticulously collected and provided links to the best research. Her books, “Blood Sugar 101” and “Diet 101,” are awesome too.
Based on the ADA criteria for an Impaired Fasting Glucose (IFG) of 100mg/dl to 125mg/dl (5.6 to 6.9mmol/L), the study found that the association between prediabetes and various co-morbidities is as follows: CVD ↑ 13%; CHD ↑ 10%; Stroke ↑ 6% and All-Cause Mortality ↑ 13%. But the ADA criteria is “contentious,” the authors told Medscape, and “has not been used in other international diabetes management guidelines.” The WHO (World Health Organization), for example, uses a higher cutoff for diagnosing an Impaired Fasting Glucose, 6.1 to 6.9mmol/L (110-125mg/dl), and thus has a higher hazard ratio for “composite cardiovascular disease” of ↑26%.
Similarly, the ADA’s prediabetes criteria for an HbA1c is 39-47mmol/mol (5.7% -- 6.4%), whereas the National Institute for Health and Care Excellence (NICE at Braiain’s NHS) cutoff, 42-47mmol/mol (6.0% -- 6.4%), is different. As a result, CVD relative risks vary from 13% (IFG-ADA) to 26% (IFG-WHO), relative risks for CHD vary from 10% to 18%, and relative risks for stroke vary from 6% to 17%. The authors also argue for the standardization of IFG and IGT (Impaired Glucose Tolerance), and the worldwide incorporation of HbA1c in defining prediabetes.
 But let’s not get lost in the weeds. The bottom line is this: The current cutoffs worldwide for a diagnosis of prediabetes are strongly associated with an increased risk of CVD, CHD, stroke and all-cause mortality. This is in addition to the usual microvascular complications of T2DM of nephropathy (end-stage kidney disease), retinopathy (blindness), and neuropathy (leading to amputations). There is also a similar pattern for dementia (Alzheimer’s).
That’s the message, and that is why I am pleased to see this hue and cry for a stricter and more standardized prediabetes definition. The medical doctor’s response was predictable: “People with diabetes should be followed up and should maintain a healthy lifestyle” (emphasis added by me). And “many drugs prescribed for diabetes may be useful in people with prediabetes (e.g., metformin, acarbose).” The latter is also not news, but it is surprising how many doctors don’t know this and do not routinely employ this intervention in clinical practice.
Then, according to Medscape, the study’s lead author, a research physician, suggests that, “First, we need to develop models for risk stratification in people with prediabetes. Second, we will select higher-risk people with prediabetes to evaluate whether drug treatment can prevent cardiovascular disease in them.” Not a word about diet.
I’m not surprised by this either. Drugs, drugs, drugs. Always treat the symptom (an elevated blood sugar); never treat the cause (Insulin Resistance → Carbohydrate Intolerance). What about “lifestyle modifications” (diet)?
Lifestyle modifications address modifiable risk factors. That means you can do something to reduce your increased risk of cardiovascular disease. You can modify your diet by restricting the amount of carbohydrates you eat and thus lower your blood sugar without drugs. Jenny Ruhl #1: ↓Dietary Carbohydrates = ↓Insulin Resistance = ↓Type 2 Diabetes.