Retrospective #332: Are you an un-diagnosed Type 2?

I recently talked for an hour or so to a friend who knows that I know a lot about Type 2 Diabetes. He sought me out to ask me what he should do. I asked him, “What is your situation?” Here’s what he told me:

His fasting blood sugars (FBG), he said, are consistently running in the 140s. That’s 140mg/dl. I told him that was “out of control.” I asked him what his postprandials were. He said he didn’t know “postprandial,” so I said rephrased it: your blood sugar 1 or 2 hours after starting a meal. He said he didn’t know. He didn’t do postprandials.

I then asked him what his latest A1c was. He replied 6.9. That’s 6.9%, but he said it was almost 2 years ago. I asked him if his doctor had told him that he was diabetic. He said “No,” and I said, “Well, you are!” The American College of Endocrinologists defines Type 2 Diabetes as an A1c of ≥6.5%. The American Diabetes Association advocates ≤7.0%, but definitions are a big part of the problem. Some clinicians today regard an A1c of ≥5.7% as full-blown Type 2 diabetes.

I asked my friend if he was currently taking any medications to control his blood sugar. He said, “Yes.” He was taking a two 500 mg tablets of Metformin twice a day, plus glyburide (micronase, a sulfonylurea). He didn’t remember how much, and I don’t remember how often he takes it, because this set me off on a rant.

I said, “You are already maxed out on Metformin” at 2000 mg/day, and you are taking a sulfonylurea (SU), a class of medications that pumps the pancreas to produce insulin to “cover” the carbs you are eating, AND IT’S NOT ENOUGH!” SUs ARE A DRUG THAT, WHILE STILL PRESCRIBED BY UNKNOWING PHYSICIANS (BECAUSE ITS CHEAP AND “EFFECTIVE”) BEAT UP AND WEAR OUT THE BETA CELLS IN THE PANCREAS THAT MAKE YOUR INSULIN, AND THEY EVENTUALLY STOP WORKING!!! RESULT: YOU WILL SOON BE INJECTING BOTH LONG ACTING (BASAL) AND MEALTIME (BOLUS) INSULIN TO CONTROL YOUR BLOOD SUGAR. And YOU haven’t even been told YOU’RE DIABETIC!!!!!!

He said, “What should I do?” I didn’t hesitate to tell him. I said, “You’ve got to change what you eat! I mean seriously change what you eat.” “What do you have for breakfast,” I asked? “Oatmeal,” he said, “with milk and a little sugar.” “Switch to eggs,” I said, “any way (fried, scrambled, poached, even hard boiled).” “How many”, he asked? “One, two or three; add a strip of bacon if you like,” I said, “but no juice, no cereal, no yogurt, bread or jelly. Only heavy cream and a little stevia in your coffee, if you must.” I told him he wouldn’t be hungry. He wouldn’t need a mid-morning snack. (When he told me he ate an apple in mid-morning because he was “starving.” I just rolled my eyes in horror.)

I also told my friend that he had to get off the SU no matter what he ate. The effect could be that his A1c will go up unless he replaced the SU with a drug that acts in a different way, sparing the pancreas, or changed what he ate. There are now several newer (but expensive) drugs, both oral and injectable, that are effective. Many clinicians would even argue reasonably that a temporary course of exogenous (injected) insulin would perhaps be the best course of treatment in his case to get his blood sugar under “good control.” BUT I WOULD ARGUE THE BEST COURSE OF TREATMENT, AND THE ONLY ONE THAT ADDRESSES THE CAUSE OF TYPE 2 DIABETES (INSULIN RESISTANCE), IS TO BASICALLY CHANGE WHAT YOU EAT.

My own experience supports this course of action. In 2002 I weighed 375 pounds and I was maxed out on Metformin and a sulfonylurea and starting a DPP-4 inhibitor (Avandia). I was, like my friend, clearly on my way to injecting insulin. My doctor wanted me to lose weight, of course, so he “prescribed” a radical change of diet, a Very Low Carb: just 20g of carbs a day. The surprising result (for both of us) was that on the very 1^st day of strict compliance I got a hypo (a low blood sugar). The doc ordered me to stop the Avandia. The next day, I had another hypo, and he told me to cut the Metformin and the glyburide (the SU) in half. A few days later I had to cut both the Met and the SU in half again. Still later, when I returned to strictly eating VLC, just 30g of carbs a day, for a year, I cut out the glyburide altogether.

After a few years or eating this very different way, I had lost 170 pounds, my blood pressure dropped to 110/70 (on fewer meds), my HDL-C more than doubled and my triglycerides dropped by 2/3rds. And I saved a ton of money on medication. And I was much, much healthier!!! And all I did was change what I ate, starting with breakfast.