Friday, May 24, 2019

Retrospective #98: The “Dreaded Complications” of Type 2 Diabetes

With the meteoric rise in the incidence of Type 2 Diabetes and obesity (“diabesity”, a cool conjunction), and their associated public health implications, the “dreaded complications” of the pandemic should now be front-and-center in the news. They do deserve our attention. They are pretty scary, and fear is a good motivator.
Here’s a truthful note from the American Diabetes Association: “Diabetes increases your risk for many serious health problems. The good news? With the correct treatment and recommended lifestyle changes, many people with diabetes are able to prevent or delay the onset of complications.” This would actually be a gross understatement, except for their use of the word “recommended.” Their “recommended” changes won’t work.
I would say that a Type 2 who follows a Very Low Carbohydrate diet can avoid the complications altogether. However, if you do not control your blood sugar by diet or other means, the NIH’s Medline Plus site tells us: “If you have diabetes, your blood sugar levels are too high. Over time, this can cause problems with other body functions, such as your kidneys, nerves, feet, and eyes. Having diabetes can also put you at a higher risk for heart disease [and] skin problems, digestive problems, sexual dysfunction, and problems with your teeth and gums.”
The order of magnitude of the risks of complications of chronic Type 2 diabetes are described in a Wikipedia entry:  In the developed world, diabetes is the most significant cause of adult blindness in the non-elderly and the leading cause of non-traumatic amputation in adults, and diabetic nephropathy is the main illness requiring renal dialysis in the United States” (emphases all mine). All of these complications are directly associated with Type 2 diabetes, and they are all the result of damage to the small blood vessels. These complications are all described as microvascular.
Today the main complications of chronically elevated blood glucose are macrovascular disease, which leads to cardiovascular disease (CVD). Wiki lists the following examples: Coronary artery disease (CAD), leading to angina or myocardial infarction (“heart attack”); diabetic myonecrosis (“muscle wasting”); peripheral vascular disease, which contributes to intermittent claudication (exertion-related leg and foot pain); and stroke (mainly the ischemic type).
In addition, Diabetic encephalopathy, the increased cognitive decline and risk of dementia – including Alzheimer’s disease – is observed in and associated with chronically elevated blood sugar, i. e. inadequately controlled Type 2 diabetes. These are just some of the risks, but I said I wasn’t going to scare the bejesus out of you. I guess I lied.
An abstract presented at a poster session at a 2012 ADA meeting is apt. It reported a Swedish observational study of 12,359 patients with poorly controlled Type 2 diabetes. None of the patients had any cardiovascular or coronary heart disease at baseline. The patients averaged 62 years of age with mean disease duration of 9 years. The average baseline A1c was 7.8% and their mean body mass index was 30. Their mean blood pressure was 140/78. 62% were taking antihypertensive (blood pressure) meds and 46% were on lipid-lowering (cholesterol) drugs.
After 5 years, the study’s investigators separated the patients into 2 groups: those whose A1c decreased by at least 1% over the 5 years (6,841) and those whose A1c remained stable or increased (5,518). At the study’s conclusion the mean A1c was 7% in the improved-control group (-0.8%) and 8.4% in the poorly controlled group (+0.7%). By then, 12% of the well-controlled group and 20% of the poorly controlled group had developed coronary heart disease (CHD). Cardiovascular disease (CVD) was present in 17% of those in the well-controlled group and 30% of the poorly controlled group. And all-cause mortality was 15% among the group with no improvement in A1c and 10% in the group with improved A1c. Thus, after adjusting for baseline risk factors during the study period, they concluded that “patients who had suboptimal glycemic control and reduced their A1c value by slightly less that 1% were 50% less likely to die within 5 years than were patients whose A1c did not improve.” Wow! A1c down <1%.
So, with an improvement in A1c of less than 1% (7.8 to 7.0%), there is still a 50% benefit. I wonder what the benefit would be for a 2% improvement in A1c? Would the increased risk of cardiovascular disease, coronary heart disease, and all-cause mortality be eliminated completely? That’s something you might want to think about.

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