Monday, January 27, 2020

Retrospective #345: How Diabetic Do You Want to Be? (Part 2)

That sounds like a stupid question, I know. Nobody wants to be diabetic. But once you’ve been diagnosed as Pre-Diabetic or Type 2, you have, for life, for better or worse, to one degree or another, a condition called Insulin Resistance (IR)). For all intents and purposes, that means you are, to some degree, Carbohydrate Intolerant. You got this way by 1) having a genetic predisposition and 2) eating too many processed carbs and sugar for too many years.
Don’t blame yourself entirely. By 1961 the AHA had come out against saturated fat and dietary cholesterol and in 1977, the Senate Select (McGovern) Committee issued their Dietary Goals of the United States, recommending we ALL eat a low-fat, high-carbohydrate diet. Both the medical and public health establishments were tragically misguided in these recommendations, and they were soon ably abetted by Agribusiness and Big Pharma.
So, if you’ve been diagnosed either Pre-Diabetic or Diabetic (Type 2), as I ask rhetorically in Retrospective #344, using the hemoglobin A1c, today’s marker for blood sugar control, “How Diabetic Do You Want to Be?”
Is an A1c of <7.0% (or <8.0% if you are elderly) the ADA target that you and your doctor are comfortable with?
Or, is <6.5% your target, to avoid being officially diagnosed a Type 2 (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 over half of the 34 years I have been a diagnosed Type 2. My doctor isn’t worried, though. He, like most, and the ADA, he considers anything under 7.0% “well controlled.”
So, to be an informed consumer/patient, you need to be armed with some facts. The following is filched from one of, if not the best, on-line sites for Pre-diabetics, Type 2s and Type 1s: Jenny Ruhl’s “Blood Sugar 101.”
Risk Quantified for Non-Diabetic A1cs and Heart Attack Risk
The Atherosclerosis Risk in Communities study tracked 11,092 black or white adults who did not have a history of diabetes or cardiovascular disease for 15 years. It found no association between fasting blood sugar and risk of heart disease, but A1c was a different story. The table below summarizes the correlation of baseline A1c with the risk of developing cardiovascular disease. [CVD]
Multivariate-Adjusted Hazard Ratio [with my translation, for the statistically challenged].
5%:                    0.96 (0.74-1.24) [If you have an A1c of 5.0%, your chance of developing CVD is just below “even.”]

5% to < 5.5%:  1.00 (reference) [In this A1c range, your CVD risk is THE SAME AS ANYONE ELSE!]

5.5% to < 6%:  1.23 (1.07-1.41) [In this range, you are almost 25% more likely than if your A1c is 5% to <5.5%.]

6% to < 6.5%:  1.78 (1.48-2.15) [In this range you are more than 75% more likely (range almost 1½ to >2 times)].

≥6.5%:              1.95 (1.53-2.48) [If your A1c is ≥6.5%, you are almost twice as likely to develop cardiovascular disease, and the range of risk is from more than 1½ times to almost 2½ times.]
Glycated Hemoglobin, Diabetes, and Cardiovascular Risk in Nondiabetic Adults. Elizabeth Selvin et al. NEJM Volume 362:800-811. March 4, 2010 Number 9. [Jenny’s source:]
Keep in mind that because these subjects were probably diagnosed as "non-diabetic" using a fasting glucose test many of those with the higher A1cs probably were diabetic at the study outset based on post-meal values. If you are recently diagnosed with diabetes and have no signs of heart disease, your risk/A1c ratio should be similar if not identical to those shown here.”
So, if your doctor is like mine (or anyone who follows the ADA Standard of Care), (s)he is going to consider anything under 7.0% to be “good control,” so you are pretty much on your own if you choose to strive to attain a lower A1c.
Fortunately, how diabetic you want to be is entirely within your control… as will be the consequences of your decision. Now you can see why I said in Part 1 (Retrospective #344) that my target A1c has been the “low 5s” (5% to <5.5%). My last lab report was a disappointing 5.7%. Too much cheating! Resolve: eat strictly Very Low Carb and take Metformin. 

Update: When I originally wrote this column in 2016, my "last lab report was...5.7%." For this 2020 Retrospective, my last lab report (12/19) was 5.3%.

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