Sunday, September 4, 2016

Type 2 Diabetes, a Dietary Disease #344: How Diabetic Do You Want to Be? (Part 1)

Setting aside for a moment the definition of “Diabetic” and “Pre-Diabetic” (It’s a can of worms.), each person who has been diagnosed with a degree of Insulin Resistance (IR) has to decide, with their doctor in most cases, the method and degree of “countermeasures” that they think is prudent to avert “the dreaded complications.”
The complications are an increased likelihood of the familiar microvascular complications: retinopathy, (leading to blindness), peripheral neuropathy (ending in amputations) and nephropathy (ultimately, end stage kidney disease with dialysis), not to mention Erectile Dysfunction (ED). They also include macrovascular complications like heart attack and stroke…and a significantly greater chance of dementia, including Alzheimer’s Disease (AD). And overall, a reduction in life expectancy of up to 10 years.
 The American Diabetes Association describes Type 2 Diabetes as a “progressive” disease. To delay (not avert) the progression, most physicians employ the “usual care” Standard of Practice and advise diet (to lose weight) and exercise (175 minutes a week). Weight gain is associated with Prediabetes and Type 2 Diabetes and falsely viewed by most doctors as a “cause” of Type 2. In truth, Type 2 diabetes is caused by Insulin Resistance , and Insulin Resistance causes weight gain. IR comes first. Weight loss, unless the diet is Low Carb and eating Low Carb becomes a “lifestyle change,” will not be permanent. And, knowing that “diet and exercise” will fail, within 3 months of a Type 2 (or Pre-Diabetes) diagnosis, most doctors will prescribe drugs, starting with Metformin.
Depending on the patient’s age and other health conditions, the doctor will have in mind a marker of glucose control. Today, the A1c blood test has become the new marker. It measures the percentage of glucose on the surface of your red blood cells. These cells have an average life of 2-3 months, so it’s considered the average level of glucose in your blood, 24/7, over that period. It’s a nifty surrogate, and inexpensive.
Here’s where it starts to get sticky. The Quest Laboratory test reports say, “According to ADA guidelines, a hemoglobin A1c <7.0% represents optimal [emphasis added by me] control in non-pregnant diabetic patients.” It goes on to say, “Different metrics may apply to specific patient populations.” This is meant to imply that as you get older (say, 75 or 80 years old), the ADA counsels your doctor to consider an A1c of <8% to be “optimal”!
Important note: the ADA considers a <7.0% A1c “optimal” for a patient already diagnosed as a full-blown Type 2. For the not-as yet-diagnosed Type 2, the Quest report gives the ADA guidelines for screening for diabetes:
<5.7%              Consistent with the absence of diabetes
5.7-6.4%          Consistent with increased risk of diabetes (Pre-Diabetes)
≥6.5%              Consistent with diabetes
The 6.5% level is the level adopted by the medical establishment’s metabolic specialists, the American College of Endocrinologists. Note how 6.5% is well below the level that the ADA considers “optimal” (<7.0 or <8.0%). What does that tell you about how confident your doctor and the medical/pharmaceutical establishment are of their (and your) ability to effectively control your blood sugar to treat your disease? That’s why, acknowledging the likelihood of failure both in achieving permanent weight loss and blood sugar control, Type 2 is considered “progressive.” You will, over time, if you follow their dietary advice, need to take progressively more medication.
So, is an A1c of <7.0% (or <8.0% if you are elderly) the target that you and your doctor have “negotiated”?
Or, is <6.5% your target, to avoid being officially diagnosed a type 2 (by current “official” medical standards)?
Or, is <5.7% your target, so you can comfort yourself with the phrase, “consistent with the absence of diabetes”?
Or, is an A1c in the “low 5s” your target? It has been for me for half of the 30 years since I was diagnosed a Type 2 Diabetic . My doctor is much more relaxed, though. He, like most, considers the ADA’s <7.0% “well controlled.”
Or, is an A1c under 5.0% your target? I know many long-term Type 2s who manage their disease this way, to their advantage, as you’ll see. Most of them do this with a combination of a strict Low Carb diet and insulin injections.
So, just how diabetic do you want to be? Next week, I will explore, by multivariate-adjusted hazard ratio (HR), the cardiovascular (CVD) risk of the choice you will make. It’s not complicated, as you’ll see.

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