Your Mileage May Vary is an expression that I didn’t put much stock in when I first read it six years ago on a Low Carb Forum for diabetics (Dr. Bernstein’s, here). I was a neophyte in the self-management of my Type 2 diabetes, even though I had been a Type 2 for 16 years. Like most of us, I suppose, I left my health care in the hands of my physician. So, in those early days of self-management – if I thought about it at all, I thought that we Type 2s were all pretty much alike.
What prompts me to write this is a recent personal experience (n = 1) with blood sugar control. My most recent HbA1c (as I write this) is 5.6. It’s been better and, of course, a lot worse. I have been eating a restricted-calorie Very Low Carb (<15g net) ketogenic diet for several months now to lose weight, and I have lost 25 pounds. Recently, five consecutive daily fasting blood glucose readings averaged 90mg/dl, with a tight range of 88 to 92). Then, at a small dinner party in our home, I ‘blinked’ (transgressed) for the first time in more than 3 months: I had less than a cup of risotto (with Osso Bucco and broccoli rabe) and a few sweets (2 cookies and 2 homemade double-bouillon-cube sized petit fours). My body hadn’t had this much starch and sugar in a long time, and it was not prepared for it. It probably never will be again. My fasting blood glucose the next morning, 12 hours later, was 120mg/dl. A day (24 hours) later, it was 117. The next day 114, the next 123, and so on. I had fallen off the ketogenic cliff. How many days will it take now to “recover” BS control?
That’s where YMMV comes in. It depends on your medical history (both the type and degree of metabolic dysfunction and when and how you and/or your doctor responded to the discovery that you were pre-diabetic or a full-blown Type 2. I was diagnosed a Type 2 in 1986, 27 years ago. The first thing my doctor did, besides advising me to lose weight on a ‘healthy’ balanced diet, was prescribe a sulfonylurea, a class of oral anti-diabetes medication (OAD med) that causes the pancreas to increase insulin secretion. At the time, a sulfonylurea was the first-line OAD med prescribed in the U. S. for type 2s. (Metformin was already in use in Europe but would not be approved in the U.S. for another 10 years after my diagnosis). When semi-starvation (restricted-calorie “balanced”) diets didn’t work, and I continued to eat carbs, the dosage was increased until I ‘maxed-out’ on this med after a few years. Years later, when Metformin was approved for use in the U. S., I eventually maxed out on that as well and I was started on a 3rd class of meds. My blood sugar continued to elude control (on a “balanced” diet), and my Type 2 disease inexorably progressed.
My Type 2 diabetes didn’t stop its progression until I changed my diet. Then it began to reverse to the point of being undetectable as long as I “eat right.” After starting to eat Very Low Carb (VLC), my blood sugars crashed, I started getting “hypos” (dangerously low blood sugars), and I was immediately forced to take fewer and fewer OAD meds. Still, it was almost five years before I completely titrated off the sulfonylurea. So, I took the sulfonylurea at some dosage level for about 21 of the last 27 years. Now, based on what we know today, what does that likely say about my remaining β-cell function? Well, I’m not a doctor, so I’ll turn to what one of my favorite diabetes specialists has been saying for years.
Ralph A. DeFronzo, M.D., in his Banting-award lecture at the 2008 Annual Meeting of the American Diabetes Association in San Francisco said, “By the time that the diagnosis of Diabetes is made, the patient has lost over 80% of his/her β-cell function…” I most recently told you this in The Nutrition Debate # 99, “Natural History of Type 2 Diabetes” linked here. He also said in the first paragraph of the full-text article published by the ADA on the NIH website here, “Sulfonylureas are not recommended because, after an initial improvement in glycemic control, they are associated with a progressive rise in A1c and a progressive loss of β-cell function.”
So, where does this leave me? Or you? Insert your own n = 1 experience, and compare the extent YMMV conforms or varies with mine. I assume that when I was diagnosed, I had lost “over 80%” of my β-cell function. After being diagnosed, I continued eating lots of carbs for another 16 years (until I started VLCing in 2002), which means my pancreas still needed to produce lots of insulin (secreted in my β-cells). The sulfonylurea that I continued to take for another 5 years, albeit at a much lower dosage on VLC to avoid hypos, continued to push my pancreas to do that. The goal was to try to control my blood sugar with medications. My doctor (and I) were relatively happy, but at what cost? My pancreas is now shot. It is burned out. I cannot tolerate eating carbohydrates without losing blood sugar control, and you know what that means. (See #98, “The ‘Dreaded Complications’ of Type 2 Diabetes,” here)So, as we saw in #99, a disease that starts with insulin resistance progresses to pancreatic β-cell burnout as it responds to that resistance. That is inexorable if you don’t dramatically change your diet, and will accelerate if you continue to take a sulfonylurea to pump-up your β-cell production. That is the “course of action” of the disease. That course will be invariable if 1) you don’t change your diet and 2) you don’t stop taking a sulfonylurea. You must do both to protect and preserve what pancreatic β-cell function you have left before it’s too late. If you choose to do 1) and 2) when you are at an early stage of this disease, YMMV from mine. If you don’t, like me, you may become totally carbohydrate intolerant.