The Nutrition Debate #181: The New AHA/ACC Statin Guidelines and Type 2 Diabetes

In The Nutrition Debate #180, here, the 3^rd category for individuals who should be on a statin, according to the recommendations of the new American Heart Association/American College of Cardiology cholesterol guidelines, is:

“Those with diabetes aged 40 to 75 years with LDL between 70-189mg/dL and without existing heart disease.”

That includes me! I’m 72 years old and my most recent LDL cholesterol (calc.) was 110. Never mind that my HDL was 90 and my triglycerides (TG) 34. My total cholesterol (TC) was 207. Do the math: The actual formula actual is LDL = TC-HDL-TG/5. In addition, by the way, my NON-HDL was 117 and my Chol/HDL ratio was 2.3!

(I wonder, by the way, what happens when I turn 76? With the new Medicare budget cuts, do they (the medical establishment and new insurance guidelines) just turn me out to pasture? Have I lived, in their collective judgment, a useful but long enough life? Without treatment, would I just be left to slowly dissipate…and then die of “natural causes?” I ask this question because category #3, “those with diabetes,” is the only category with age guidelines for statin treatment.

So, my issue with this #3 category (besides the age question) is with the unqualified phrase “those with diabetes.” Even Ann Peters, MD, writing about “How do New Statin Guidelines Affect Diabetes Care?” for Medscape Medical News here, had to “ponder these guidelines” that “lump people with type 1 and type 2 together.” “I don’t think that type 1 and type 2 diabetes share similar features, at least not similar features with respect to the metabolic syndrome in all patients.” She treads lightly here, but I get her point. The clinician in practice needs to consider their individual patients. Bravo, Dr. Peters!

Dr. Peters describes herself “as one of the authors of the new diabetes position statement on the treatment of hyperglycemia” and “a diabetes specialist.” So, as a fixture of the establishment, she comes home to the AHA/ACC fold:

“So I think I will still monitor lipid panels. Perhaps not for absolute numbers, but to see that a patient is responding to therapy -- maybe as a marker for the fact that my patients are taking their therapy, and also to reinforce patients with some of the benefit from the treatments and lifestyle changes they have made, which I think can still be had along with the use of statin therapy in these high-risk individuals.”

“High risk individuals”? That’s how ALL diabetics are categorized by these new statin guidelines. That includes not only type 1s, as Dr. Peters mentions and then carves out an exception for in her piece, but ALL type 2s as well, regardless of “the benefits of the treatments and  lifestyle changes they have made.” Of course, by “treatments” Dr. Peters is referring to “my patients (who) are taking their therapy,” by which she means drugs. And by “lifestyle changes” Dr. Peters is referring to “diet and exercise,” although certainly not the low-carb, high-fat Way of Eating that is followed by this type 2 diabetic.

The medical establishment’s justification for this all-inclusive position with respect to diabetics is that, as Dr. Peters explains, “…regardless, (all) patients with diabetes are considered to be at high risk.” Thus, “Depending on their 10-year risk for an event, whether or not it’s greater than 7.5%, they are put on either a moderate-intensity statin regimen or the high-intensity statin regimen. But they are all put on statins if they are between the ages of 40 and 75.” After that they can eat all the fudge they want. Why not! Type 2 diabetes is “progressive” for all who are “treated” by medical association standards and insurance guidelines. So, with standard nursing home care, where they will be given basal and mealtime insulin, even if their glucose control is less than perfect, and allowed to die of some other cause, such as heart disease or dementia.

In contrast, patients who have well-controlled type 2 diabetes, by eating a Very Low Carb diet, will have very good A1c’s, with stable blood glucose all day long, low blood pressure, low systemic inflammation, and great lipids including high HDL and low triglycerides, all without “taking their therapy”…since medical treatment for hyperglycemia will be unnecessary and unwarranted. But this doesn’t occur to Dr. Peters because her clinical practice as a diabetes specialist is for people who need a diabetes specialist. If you treat yourself by the dietary choices you make, you will not need to see her, or her ilk.

You will not, however, be spared the likelihood of this altogether unappealing nursing home outcome if you follow the AHA/ACC Lifestyle Modifications that accompany the new AHA/ACC Cholesterol Guidelines. The Lifestyle Modifications recommended are the same-old, same-old: “Consume a dietary pattern that emphasizes intake of vegetables, fruit and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts, and limits intake of sweets, sugar-sweetened beverages and red meats, ” with special emphasis on lowering saturated fat and sodium intake. And “to achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA diet. And to exercise more, 3 to 4 sessions per week, lasting on average 30-40 minutes per session. As if to “throw a bone” to the type 2’s, they do allow that you could “adapt this dietary pattern to…nutrition therapy for other medical conditions (including diabetes mellitus).” They must have read the new ADA dietary guidelines described in The Nutrition Debate #155.