Sunday, January 26, 2020

Retrospective #344: How Diabetic Do You Want to Be? (Part 1)

Setting aside for a moment the definitions of “Diabetic” and “Pre-Diabetic” – it’s a can of worms – each person who has been diagnosed with a degree of Insulin Resistance (IR) has to decide, with their doctor in most cases, the method and degree of “countermeasures” that they think is prudent to avert “the dreaded complications.”
The complications are an increased likelihood of the familiar microvascular complications: retinopathy, (leading to blindness), peripheral neuropathy (ending in amputations) and nephropathy (ultimately, end stage kidney disease with dialysis), not to mention Erectile Dysfunction (ED). They also include macrovascular complications like heart attack and stroke…and a significantly greater chance of dementia, including Alzheimer’s Disease (AD) and various cancers. And overall, a reduction in life expectancy of up to 10 years.
The American Diabetes Association describes Type 2 Diabetes as a “progressive” disease. To DELAY (not avert) the progression, most physicians employ the “usual care” Standard of Practice and advise diet (to lose weight) and exercise (175 minutes a week). Weight gain is associated with Prediabetes and Type 2 Diabetes and falsely viewed by most doctors as a “cause” of Type 2. In truth, Type 2 diabetes is caused by Insulin Resistance, and Insulin Resistance causes weight gain too. IR comes first. Weight loss, unless the dieter is eating Low Carb as a “lifestyle change,” will not be permanent. And, knowing that “diet and exercise” will fail, within 3 months of a Type 2 (or Pre-Diabetes) diagnosis, most doctors will prescribe drugs, starting with Metformin (Glucophage).
To measure the degree of progressivity of the disease, the doctor will then do periodic follow-ups with A1c tests. A1c’s measure the percentage of glucose on the surface of your red blood cells, which have an average life of 2-3 months. It’s a marker for the average level of glucose in your blood 24/7. It’s a nifty surrogate, and inexpensive.
Here’s where it starts to get sticky. The Quest Laboratory reports say, “According to ADA guidelines, a hemoglobin A1c <7.0% represents optimal [my emphasis] control in non-pregnant diabetic patients.” It goes on to say, “Different metrics may apply to specific patient populations.” The ADA Clinical Guidelines counsel your doctor to consider an A1c of <8% to be “optimal” for 75 or 80 year olds!
Important note: the ADA considers a 7.0% A1c “optimal” for a patient already diagnosed as a full-blown Type 2. For the not-as yet-diagnosed Type 2, the Quest report gives the ADA/ACE guidelines for screening for diabetes:
<5.7%                    Consistent with the absence of diabetes
5.7-6.4%               Consistent with increased risk of diabetes (Pre-Diabetes)
≥6.5%                    Consistent with diabetes
The 6.5% level is the level adopted by the American College of Endocrinology, the medical establishment’s metabolic specialists. Note: 6.5% is WELL BELOW the level the ADA considers “optimal” (<7.0% or <8.0%). What does that tell you about how confident the medical/pharmaceutical establishment are of their (and your) ability to effectively control your blood sugar to treat this disease? That’s why, by acknowledging the likelihood of failure to achieve permanent weight loss and good blood sugar control, Type 2 is considered “progressive,” IF YOU FOLLOW THEIR DIETARY ADVICE. Over time, you will take progressively more medication. Your diabetes will be progressive.
So, is an A1c of <7.0% (or <8.0% if you are “elderly”) the ADA target that you and your doctor have “negotiated”?
Or, is <6.5% your target, to avoid being officially diagnosed a Type 2 diabetic (by current ACE standards)?
Or, is <5.7% your target, so you can comfort yourself with the phrase, “consistent with the absence of diabetes”?
Or, is an A1c in the “low 5s” your target? It has been for me for > half of the 34 years since I was diagnosed a Type 2 Diabetic. My doctor is much more relaxed, though. He, like most, considers the ADA’s ≤7.0% “well controlled.”
So, HOW DIABETIC DO YOU WANT TO BE? Tomorrow I will show you the “multivariate-adjusted hazard ratios” (HRs) for the cardiovascular disease (CVD) risk of the choice you will make. It’s not complicated, as you’ll see.

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