Wednesday, July 10, 2019

Retrospective #144: Diabetes and Dementia

The “Background” in the Abstract of this August 2013 piece in The Lancet states: “Although patients with Type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10-year dementia risk for individuals with Type 2 diabetes.” Diabetes in Control, a digest for medical doctors to which I subscribe, picked it up. Have I got your attention yet? Well, it gets much scarier.
The researchers were from the University Medical Center Utrecht, Netherlands, the University of Chicago, the University of Washington, and Kaiser Permanente. In 2013 Kaiser Permanente was the largest managed care organization in the U. S., with almost 9 million health plan members, 15k doctors, 170k employees, and $50 billion in annual revenues. Kaiser Permanente, the National Institute of Health, and Fulbright funded the study.
The researchers used data from patients with Type 2 diabetes, aged ≥60 years, with 10 years of follow-up. The risk factors in their analysis that were “most strongly predictive of dementia” were “microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education.”
The outcome of their risk analysis? “The prediction of 10-year dementia risk in patients with Type 2 diabetes mellitus “shows a 5.3% risk for the lowest score and 73.3% for the highest score. The Diabetes in Control piece states, “According to the authors of this study, those in the higher risk category were 37 times more likely to develop dementia than those in the lowest risk category.”
How do they plan to use this information? You’ll love this. They say, “The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials” (my emphasis). And that’s it! In other words, they watch as you develop dementia, and then perhaps suggest that you sign up for a clinical trial to test another drug to treat your cognitive deterioration. Isn’t that just dandy!
Of course, there is another way. Remember, the researchers who created and tested this risk analysis prediction tool used “data from approximately 30,000 Type 2 diabetic patients aged 60 and greater over a 10-year interval.” These diabetics were presumably being advised to eat a “one-size-fits-all” low-fat, high-carb, restricted-calorie diet, with lots of “healthy fruits and vegetables” (all carbohydrates) with minimum saturated fat and dietary cholesterol.
Most were probably also medicated for hypertension (high blood pressure) and for high cholesterol with statins.
Further, the treatment standard that the clinicians were using was undoubtedly the one supported by the current “Standards of Medical Care in Diabetes” published annually in Diabetes Care, the Journal of the American Diabetes Association. That means that your physician will be safe-guarded from medical liability to simply advise you that your Type 2 diabetes is “under control.” He will not inform you that your elevated blood glucose levels, as allowed by this standard, are progressively damaging your blood vessels, organs and endocrine system.
If you leave the care of your Type 2 diabetes in the hands of your physician, this is what will happen to you: As he observes your A1c rise, he or she will prescribe higher doses and more medications until you are maxed out, and then possibly switch you to injected insulin. Repeat for your elevated cholesterol and high blood pressure.
And when you are unable to lose weight and keep it off on a low-fat, high-carb diet, as he makes a note in your file that the “patient was non-compliant,” you will be reminded again to “eat less and exercise more.”
Don’t be a member of this treatment cohort. Take charge of your own health. Do not accept an A1c of ≤7.0% as “in control.” At this level, your heart attack risk is doubled. Eat a diet that is low in carbohydrates; better yet, VERY low. Don’t sweat the saturated fat and dietary cholesterol. Your body will love it. And so will your doctor. He or she will be pleasantly perplexed with your lab results and weight loss, and will almost certainly lower your meds, and then tell you to “just keep on doing what you’re doing.” That’s an outcome you can both happily live with.

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