Wednesday, August 13, 2014

The Nutrition Debate #235: Self- vs. medical management of T2DM

1,750,000 “hits” on the subject of self-management of type 2 diabetes in my initial Google search; that’s lots of advice, the vast majority of which is, in my humble opinion, really bad. So, in this sea of flotsam and jetsam, there wouldn’t be much chance of your finding my little rubber ducky (#235). Besides, this post is going to show you how almost any well-designed program of self management of type 2 diabetes is far superior to any ADA/AHA/AMA/USDA designed protocol. The differences will astound you, I promise. And the benefits to you, “the patient,” will be demonstrable.

To show superiority, we will need a basis for comparison. In the case of type 2 diabetes, that would be the Standard of Care set by the American Diabetes Association.  They, in turn, will comply with the government’s standards of “insurance” reimbursement for Medicare and Medicaid patients, to which private insurers also generally conform. And since type 2 diabetes is a medical condition that is generally associated with a raft of other disorders and conditions, including obesity, metabolic syndrome, dyslipidemia, hypertension, and cardiovascular disease, the Standards of Care and standards of insurance reimbursements for these conditions must also be factored.

So, when you “present” as an overweight middle-aged person, with elevated fasting glucose (>100 but <126mg/dL) or an A1c that is “increased risk of diabetes” (5.7-6.0%) or “higher risk of diabetes” (6.1-6.4%), if you’re lucky, you’re given metformin and told to “lose weight.” Not so lucky and you’re only told, “Your glucose is a little high” and “We’ll watch it.”

You’re probably already on a cocktail of blood pressure meds for your obesity-related hypertension, and if you’ve been eating a low-fat, high-carb diet as recommended by the Dietary Guidelines for Americans since 1977, you probably also have high triglycerides, low HDL, and high LDL, with a total cholesterol over 200mg/dL. So, you’re on a statin too, to lower your LDL and Total Cholesterol (because that’s what statins do) in conformance with the National Cholesterol Education Program (NCEP) Standard of Care (another one of those government standards).

Your doctor, whether he or she is a general practitioner or a specialist, has to treat you for this complex of conditions. For example, an endocrinologist (a hormone specialist!) that I went to see recently (without a referral), wanted to prescribe a statin for me because my total cholesterol was over 200 (and I have other risk factors: hypertension and type 2 diabetes). It did not matter to him that my total cholesterol (207mg/dL) was over 200 because my HDL was 90. My LDL was 117 and my triglycerides 34. I wonder if he knew about the Friedewald formula: TC = LDL + HDL + TG/5. All that mattered to him was, to conform to the NCEP Standard of Care (and insurance payment/review criteria), that I be on a statin. I refused.

The Dietary Guidelines for Americans are similarly one-size-fits-all. Everyone, regardless of metabolic status, should eat the same low-fat, high carb diet. But the pendulum is beginning to swing. Now we’re told to eat less sugar and highly processed carbs (that’s good advice). We’re now also told that it’s the quality, not the quantity, of fat that matters. They say shun trans fats (good advice) and eat more vegetable and seed oil and less saturated fat (that’s bad advice). Still, the government’s one-size-fits-all standards are way behind the curve. In addition, they have been hopelessly corrupted by industry influence at the USDA. It’s bad news, period.

The American Diabetes Association has similar standards. It used to be one-size-fits all, and the Standard of Care, to achieve an A1c of < or = to 7.0%, hopelessly lax. This catastrophic Standard of Care was and still is a function of a failed treatment protocol. And it is a failed treatment protocol because of the government’s insistence on a low-fat, high carb one-size-fits-all diet for the American population. And now they want to lower the Standard of Care. See #230 here.

Never mind that that this dietary is what has made the population fat. Never mind that all carbohydrates raise your blood glucose. At the very least, once you “present” as an overweight middle-aged person, with elevated fasting glucose (>100 but <126mg/dL) or an A1c that is at “increased risk of diabetes” (5.7-6.0%) or “higher risk of diabetes” (6.1-6.4%), your doctor should tell you (as mine did) to drastically curtail your intake of carbohydrates. My doctor suggested I start on 20 grams of carbohydrate a day to lose weight. I did. I lost lots of weight.

 And I also was able to give up virtually all of my oral diabetes meds. And my blood pressure went from 130/90 to 110/70 on the same meds. And my HDL more than doubled. And my triglycerides dropped by two-thirds. And I no longer, of course, need a statin. This treatment protocol, which I self-monitor by watching what I eat and monitoring my blood sugar to a much higher standard than prescribed by the American Diabetes Association and my doctor, is clearly far superior to the one-size-fits-all medical standard that our government and the medical establishment continue to use to treat T2DM.
What’s your HDL level?  Or does your doctor even care? You see, there’s no ‘magic pill’ to get your HDL up above the 40mg/dL range, which is considered borderline ‘bad’ for men (45mg/dL for women). Only a low-carb diet can do that. And lower your triglycerides too.

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