Wednesday, May 29, 2019

Retrospective #103: Your Mileage May Vary (YMMV)

Your Mileage May Vary (YMMV) is an expression that I didn’t put much stock in when I first read it years ago on a Low Carb Forum. I was a neophyte in the self-management of my Type 2 diabetes, even though I had been a Type 2 for 16 years. Up until then, like most of us, I had 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 prompted me to write about this [in 2013] was a personal experience I had with my blood sugar (BS) control. My most recent A1c was 5.6%. It’s been better and, of course, worse. I had been eating a restricted-calorie, Very Low Carb (+/-15g) ketogenic diet for several months to lose weight and had lost 25 pounds. Five consecutive daily fasting blood glucose readings averaged 90mg/dl, with a tight range. Then, at a small dinner party in our home, I ‘blinked’ (transgressed): I had about a cup of risotto (with Osso Bucco and broccoli rabe) and some dessert (2 homemade cookies and 2 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. My fasting blood glucose the next morning was 120mg/dl. The next day my FBS was still 117. The next day 114, the next 123, and so on. I had fallen off the ketogenic cliff and had lost 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 diagnosed Type 2. I was diagnosed in 1986. The first thing my doctor did, besides advising me to lose weight (“eat less on a ‘healthy’ balanced diet”), was to prescribe a sulfonylurea (SU), a class of oral anti-diabetes medication that makes the pancreas produce more insulin. At the time, sulfonylureas were the only oral anti-diabetes medication prescribed in the U. S. When I continued to eat carbohydrates, and the SU didn’t get my BS under control, my dose was increased until I was ‘maxed-out’ on this med. Then, when Metformin was approved for use in the U. S., I started on and eventually was maxed out on it too and started on a 3rd oral med. On a “balanced” diet, however, my blood sugar continued to elude control, and my Type 2 diabetes inexorably progressed.
My Type 2 diabetes didn’t stop its progression until I changed my diet. In fact, it reversed to the point of being undetectable as long as I “eat right” (VLC). After starting to eat Very Low Carb (VLC), in the first week I forced to take fewer and fewer oral anti-diabetic meds. Still, it was almost five years before I completely titrated off the SU, so I took an SU at some dosage level for 21 years. So, I wondered, what effect did this have on my pancreas?
Well, I’m not a doctor, so I’ll refer instead to what one of my favorite diabetes specialists, Ralph A. DeFronzo, M.D., has been saying for years. In his Banting-award lecture at the 2008 Annual Meeting of the American Diabetes Association in San Francisco, Dr. DeFronzo said, “By the time that the diagnosis of Diabetes is made, the patient has lost over 80% of his/her β-cell function.” He also said in the first paragraph of the full-text article published by the ADA on the NIH website, “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? If I had lost over 80% of my β-cells upon being diagnosed, and continued eating a “balanced” diet (with lots of carbs) for another 16 years, my pancreas still needed to make insulin with fewer β-cells. The SU continued to push it to do that because the goal was to control my blood sugar with medications.
So, 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. It will likely accelerate if you continue to use a sulfonylurea to get your pancreas to pump insulin. That is the “course of action” of the disease. That course will be inexorable 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 both 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. And like me, you will not be able to “cheat” from time to time and get away with it.

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