Saturday, April 27, 2013

The Nutrition Debate #103: Your Mileage May Vary (YMMV)

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.


  1. Dan, this is an excellent post. Thanks for sharing your n=1 experience of consuming a few high-carb foods after eating VLC for several years. Wonderful that you experienced such dramatic improvement in BG control that you were able to discontinue all diabetes meds despite having had DM for more than a decade. YMMV is indeed true, and like you I advise people to "eat to your meter." I'm personally too afraid of "meter shock" to indulge in any high-carb foods but can keep my BG within normal range as long as I keep total carbs below 50 grams a day.

    1. Thanks, Franziska. It means a lot to me to have such high praise from you. My immediately preceding column (#102), "Denial is not..." goes hand in hand with this one too.

      I am happy with (resigned to?) my food choices now, but at <15g CHO/day, they are really, really limited. The benefit of early recognition and lifestyle (diet) change is, as you imply, that YOU can eat 50g/day w/o dire repurcusions, which is a place I will never be at again (w/o mealtime insulin).

      That is the lesson. That is the takeaway, as you so subtly imply. I am envious, of course, but people reading this should see it as an incentive and motivate them to change.

      Thanks for commenting, and keep up the good work. I am a great admirer of your "Low Carb Dietitian" site and blog.

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    3. Limiting carbs to less than 15 grams daily is very challenging, and your ability to do so is very impressive. It is an amazing feat to be off medications despite significant loss of beta cell function. That is obviously a strong motivator for you, along with your amazing weight loss.

      Thanks for your continued support of my work and blog as well :)

    4. Once more, back at you. I wrote YMMV last December, but in late January visited an endo (for the 1st time in over 20 years) and asked for a HOMA Assessment test. He had NEVER ordered one for a patient, both he and his PA said, but he agreed to do it. (He also said to do it I would need a serum insulin test, as I recall.) I was very surprised to learn from it that my Beta cell function was 68% and my Insulin Sensitivity, which is the inverse of Insulin Resistance, was 94.6%. This was all the more surprising due to my 20 year history on a sulfonylurea. It suggests (to me) regeneration of beta cells and a very recuperative quality to the cell barriert that enables glucose to be 'taken up' by the body. You, as a CDE and RD, might be interested in these two statistics. They provided me with additional hope, or shall I say less reason to despair, at being such a long time medicated T2.

      You can read about my experience in my blog posts #86 and #87. Please excuse my intemperance, if you can. I have grown impatient with arrogance (in others).

    5. Wow, what an accomplishment! I wasn't aware insulin sensitivity could be restored to that extent. Extremely interesting and encouraging!

      Thanks for alerting me about your other blog posts. I will try to read them very soon :)

  2. Once again, your report helps me get a clearer picture of my own diabetes and keep myself out of trouble. Thank you.

  3. Thanks, Jan. As always, your feedback and support is tremendously encouraging. It's great to have loyal and longtime 'members' like you, as well as new ones. Site visits are accelerating and are now up to the rate of over 2,500 a month from just 1,000 a month at end of January (3 months ago).