Wednesday, September 18, 2013

The Nutrition Debate #144: Diabetes and Dementia


I have been contemplating a whole series on the subject of diabetes and dementia for some time, but this one just begs to be written now. This article in Diabetes in Control, a digest for medical doctors, was reprinted on 8/31/13 from a piece that originally appeared in issue 692 of Neurology. It in turn was based on an abstract published in The Lancet: Diabetes and Endocrinology on August 20, 2013 here. All these articles deal with the risk of type 2 diabetics developing dementia.

The Background in the Abstract of The Lancet piece states: “Although patients with type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10 year dementia risk for individuals with type 2 diabetes.” Have I got your attention yet? Well, it gets much scarier.

The researchers were from the University Medical Center Utrecht, Netherlands, the University of Chicago, the University of Washington, and Kaiser Permanente. Kaiser Permanente is the largest managed care organization in the U. S. It has almost 9 million health plan members, 15k doctors, 170k employees, and $50 billion in annual revenues. Funding for the study included Kaiser Permanente Community Benefit, the National Institute of Health, and Fulbright.

The researchers used data from two cohorts of patients with type 2 diabetes, aged ≥60 years, with 10 years of follow-up. The risk factors in their statistical analysis that were “most strongly predictive of dementia” were “microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education.”

And what was the outcome of their risk analysis? “The prediction of 10 year dementia risk in patients with type 2 diabetes mellitus“shows a 5.3% risk for the lowest score and 73.3% for the highest score. The Diabetes in Control piece states, “According to the authors of this study, those in the higher risk category were 37 times more likely to develop dementia than those in the lowest risk category.”

How do they plan to use this information? You’ll love this. They say, “The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials.” And that’s it! In other words, they watch for (“be vigilant”), i.e. observe, as you develop dementia, and then perhaps suggest that you sign up for a clinical trial to test another pharmaceutical product(s) to treat your cognitive deterioration. Isn’t that just dandy!

Of course, there is another way. Remember, the researchers who created and tested this risk analysis prediction tool used “data from approximately 30,000 type 2 diabetic patients aged 60 and greater over a 10-year interval.” These diabetics were presumably being advised to eat a “one-size-fits-all” low-fat, high-carb, restricted-calorie dietary regimen, with lots of “healthy fruits and vegetables” (all carbohydrates) with minimum saturated fat and dietary cholesterol. They were probably being medicated for “high cholesterol,” hypertension (high blood pressure), and high triglycerides and low HDL-cholesterol symptoms of metabolic syndrome); and with other drugs for various neuropathies and co-morbidities associated with type 2 diabetes.

Further, the treatment standard that the clinicians were using was undoubtedly the one “supported by the current ‘Standards of Medical Care in Diabetes’ published every January in Diabetes Care, the Journal of the American Diabetes Association:” http://care.diabetesjournals.org/content/36/Supplement_1/S11.full That means that your physician will be content, or at least safe-guarded from medical liability, to simply advise you that your type 2 diabetes is “under control.” He will not inform you that your elevated blood glucose levels (as allowed by this standard) are progressively damaging your blood vessels, organs and endocrine system.

If you leave the care of your type 2 diabetes in the hands of your physician, this is what will happen to you: As he observes your A1c rise, he or she will prescribe more of the same medication, and when you are maxed out on that, he or she will write a script for another, and then possibly a third (before switching you to injected insulin). Repeat for your elevated cholesterol and high blood pressure. And when you are unable to lose weight and keep it off on a low-fat, high carb diet, you will be reminded again to “eat less and exercise more,” as he makes a note in your file that the “patient was non-compliant.”
I would like to suggest an alternative: Don’t be a member of this treatment cohort. Take charge of your own health. Do not accept an A1c of 6.5% as “in control.” At this level, your heart attack risk is doubled. Eat a diet that is low in carbohydrates; better yet, very low. Don’t sweat the saturated fat and dietary cholesterol. Your body will love it. And so will your doctor. He will be perplexed at how wondrous your lab results are. He will likely have to lower your meds, and he will tell you to “just keep on doing what you’re doing.” And if he perchance asks you how you did it, you might tell him. It’s time doctors took off their blinders and used current best evidence in making decisions about the care of individual patients. Your individual results, like mine, could be very impressive indeed.

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