Friday, August 16, 2019

Retrospective #181: The AHA/ACC Statin Guidelines and Type 2 Diabetes

In Retrospective #180, the 3rd category for individuals who should be on a statin, according to the American Heart Association/American College of Cardiology cholesterol guidelines, are the following individuals:
“Those with diabetes aged 40 to 75 years with LDL between 70-189mg/dL and without existing heart disease.”
That’s me, sort of, although I’m now 78 years old. My most recent LDL cholesterol (Martin Hopkins calculation) was 92. Never mind that my HDL was 80 and my triglycerides (TG) 56 and my total cholesterol (TC) was 186mg/dL.
As an important aside, though, I wonder, at my age (>75yo), with the Medicare budget cuts (+/-$750 Billion over 10 years) that were required to fund the Affordable Care Act, aka “Obamacare,” does the medical establishment just turn me out to pasture, as they would in most of Europe? Have I lived, in the government’s judgment, a useful but long enough life? Would I be just left, without treatment, to slowly dissipate…then die of “natural causes?” I ask because category #3, “those with diabetes,” is the only category with age guidelines for statin treatment.
But my issue with category #3 is with the phrase “those with diabetes.” Even Ann Peters, MD, writing about “How do New Statin Guidelines Affect Diabetes Care?” for Medscape Medical News, had to “ponder these guidelines” that “lump people with type 1 and type 2 together.” “I don’t think that type 1 and type 2 diabetes share similar features, at least not similar features with respect to the metabolic syndrome in all patients.” She treads lightly here, but I get her point. The clinician in practice needs to consider their individual patients. Bravo, Dr. Peters!
Dr. Peters describes herself “as one of the authors of the new diabetes position statement on the treatment of hyperglycemia” and “a diabetes specialist.” So, she is a fixture of the medical establishment, with a distinction:
“So, I think I will still monitor lipid panels. Perhaps not for absolute numbers, but to see that a patient is responding to therapy -- maybe as a marker for the fact that my patients are taking their therapy, and also to reinforce patients with some of the benefit from the treatments and lifestyle changes they have made, which I think can still be had along with the use of statin therapy in these high-risk individuals.”
“High risk individuals”? That’s how ALL diabetics are categorized by both these new statin guidelines and Dr. Peters. That includes not only type 1s, but ALL Type 2s as well, regardless of “the benefits of the treatments and lifestyle changes they have made.” By “treatments” Dr. Peters means drugs. And by “lifestyle changes” Dr. Peters means “diet and exercise,” although certainly not the very-low-carb, high-fat (VLCHF) Way of Eating that I espouse.
The medical establishment’s justification for this all-inclusive position for all diabetics is that, as Dr. Peters explains, “…regardless, [all] patients with diabetes are considered to be at high risk.” Thus, “Depending on their 10-year risk for an event, whether or not it’s greater than 7.5% (see category #4 in #180), they are all put on statins if they are between the ages of 40 and 75.” After age 75, in time, with standard nursing home care, they will be injected with basal and mealtime insulin and allowed to die of some other cause, such as heart disease or dementia.
In contrast, by eating a Very Low Carb diet, patients who have well-controlled Type 2 diabetes will have very good A1c’s, with stable blood glucose all day long, low blood pressure, low systemic inflammation, and great lipids including high HDL and low triglycerides, all without “taking their therapy”…since medical treatment for hyperglycemia will be unnecessary and unwarranted. But this doesn’t occur to Dr. Peters because her clinical practice is for people who need a “diabetes specialist.” If you treat yourself by the dietary choices you make, you will not need a diabetes specialist.
If, however, you’re a Type 2 and you follow the Lifestyle Modifications that accompany the new AHA/ACC Cholesterol Guidelines, your diabetes will be progressive as you “…consume a dietary pattern that emphasizes intake of vegetables, fruit and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts, and limits intake of sweets, sugar-sweetened beverages and red meats, ” with  emphasis on lowering saturated fat and sodium intake. And you will need a diabetes specialist… and a cardiologist too!

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