Type 2 Diabetes, a Dietary Disease #370: My 2-Month, 20-lb Challenge, 1st wk Progress Report

As you read this I will be 4 weeks into my 2-month, 20-pound challenge, but I write after only 1 week “in.” If you don’t know what prompted me to do this challenge, read #368 here to learn my motivation and other particulars. The short report: in the 1^st week I dropped 11 pounds and lowered my FBG average by 19 points to 100mg/dl. If you’re overweight (as I am) and prediabetic or a 30-year diagnosed type 2 (as I am), even though theoretically “in remission,” and that outcome doesn’t pique your interest, you may as well stop reading.

The “challenge” is to stay on my current eating pattern 5 days a week and to fast on the other two. My current eating pattern is coffee with pure stevia powder and 1½ oz of 36% full cream in the morning. Then, only if I am hungry during the day, to eat either a light lunch (smoked herring in brine), a “big” lunch (brisling sardines in EVOO), or a snack (HB egg). My main meal (supper) is a stove-top preparation of cod with vegetables or a veal stew. Alternatively, I could make tripe in salsa roja or veal kidney with mushrooms, onions and Marsala.

This week I had cod with tomatoes, green olives and red pepper flakes Sunday and Monday. Then, I bought 2 pounds of tripe and made 4 suppers: Wednesday, Friday, Saturday and Sunday. I fasted on Tuesday and Thursday. On fasting days, besides my morning coffee, I had 1 red wine spritzer at the supper hour, and on the other days I had 2 red wine spritzers.

Next week (M, W) I will do different cod preparations (fennel and/or celery in chicken broth). I’ll also make a romaine salad with mushrooms, hazel nut pieces and shaved Pecorino Romano, with a vinaigrette.

During the last week I ate a light lunch (2 HB eggs) the day after the 1^st fast day and a snack (1 HB egg) after the 2^nd fast day. Saturday, I had a small can of pork liver pâté for lunch. There was no other need or occasion to have “lunch” or to snack during the day or after supper. Saturday night, after attending a jazz concert, I went “off plan” and stopped at a restaurant on the way home and had 2 stingers in front of a roaring fire.

And that’s all there was to it, folks. Eleven pounds (okay, half or more water), but the pounds just dropped off after each full day of fasting. My body maintained a high metabolic rate (translation: I felt great and had lots of energy and no hunger or cravings). It did this by transitioning from obtaining energy from the food I ate (S, M, W, F, S) to obtaining energy from breaking down and burning my body fat on Tuesday and Thursday.

My perennial goal is to maintain my FBG average below 100mg/dl (and keep it low and steady during the day). I hope thus to reduce my A1c from the current 5.8% to 5.5% or lower. I haven’t seen 5.5% in a few years.

My interim weight goal for this 2 month challenge is to get down to 228 (BMI=32). That’s still considered “obese” in the BMI chart. So, I can’t derive too much satisfaction from the first week. I have to persist and be satisfied with a slower pace going forward, spiked each week no doubt by the 2 full days of fasting.

I have to remind myself that several years ago I lost 100 pounds in a year (without full-day fasting) by strictly adhering to Bernstein. But the fasting part is not difficult since you don’t experience hunger or cravings. As I read in a tweet this week (@SBakerMD), “Beat cravings and you win.” He’s right, of course. That’s the beauty of a Very Low Carb Ketogenic Diet. By the way, Dr. Baker eats an all-meat (grass-fed) diet (“zero carb”).

So, that’s the 1^st week’s progress report. I’ll write another next week (2 weeks “in”). I expect progress to slow a lot, but I am hopeful that my FBG average will drop below 100 and that the weight loss will continue apace.

I fully expect to continue to feel great and have lots of energy and no hunger, including on fasting days.

Type 2 Diabetes, a Dietary Disease #369: “759 Secrets for Beating Diabetes”

I’m not joking; “759 Secrets for Beating Diabetes” is the actual title of a Reader’s Digest book. I saw it (on deep discount) in the vestibule of my local Barnes and Noble. I’m not surprised, really. Of course, the fact that it was published is proof that the “secrets” are no longer secret, whatever they were. I know, calling them “secrets” is a rhetorical trick publishers use to pique your interest. It is possible, though, that no one bought the book.

However, 759 is an awful lot of “secrets” to slog through to learn how to “beat diabetes.” And how would you decide which of 759 “secrets” to try? No one could try them all! Maybe that’s the reason it didn’t sell well.

To tell you the truth, I didn’t open the book. I’m just assuming an editor had the idea to amplify on one aspect of the frequently heard advice that “beating diabetes” requires a LIFESTYLE CHANGE. And lifestyles are multi-factorial. But 759 factors? Maybe the editor read somewhere that, since a “CALORIE IN = CALORIE OUT,” the way to beat diabetes was to “MOVE MORE AND EAT LESS” or “DIET AND EXERCISE” or “EAT HEALTHY.” These are all familiar, if erroneous, memes, and all lacking in specifics. So, the editor thinks, let’s tell the folks 759 ways to make a lifestyle change! Then, let the reader pick. But with so many, isn’t it likely that some will be contradictory?!!!

Okay, I’ve had enough fun with this BS. But the reason I had this reaction to the ridiculous title of that book is: There is just ONE secret to beating diabetes: “EAT SMART!” IF EATING CARBOHYDRATES, INCLUDING SIMPLE SUGARS, AND REFINED AND PROCESSED CARBOHYDRATES, AND SUGARY DRINKS, AND FRUIT, MAKES YOUR BLOOD SUGAR RISE, THEN THE SECRET TO BEATING DIABETES IS TO NOT EAT CARBS. THAT’S EATING SMART!

Hey, I lost 170 pounds by just eating, strictly, Very Low Carb (VLC). I lost the first 60 on Atkins Induction (20g of carbs a day). Then, after a few years of maintaining that loss, I gained 12 pounds back over a summer. So, having just read Richard K. Bernstein’s “Diabetes Diet,” I lost another 100 over a year, and then another 20 later. Bernstein’s program is 30g a day. Today, 15 years later, I am still 150 pounds lighter than when I began.

Back in 2002 when I started to eat VLC, to avoid hypos in the first week I had to stop taking most of my oral antidiabetic medications. I was maxed out on two and had just started a third. Today, I only take Metformin. Along the way my HDL doubled, my triglycerides dropped by 2/3rds and my blood pressure improved on the same BP meds. My chronic systemic inflammation marker (hsCRP) is <1.0. My A1c’s are consistently in the 5s.

And the (other) good news is: I’m never hungry or tired. Eating VLC means my metabolism operates at a high level because after my body digests the low-carb foods I eat, to maintain energy balance (“homeostasis”), my body transitions from the “fed” state to breaking down and burning fat that is stored in my body (the “fasting” state). It can do this because, although as a type 2 diabetic I do have insulin resistance (IR), my serum insulin levels remain low because my serum glucose levels remain low because I abstain from eating carbs!

This enables my body to access the body fat for energy without slowing down my metabolism. Body fat is in the form of triglycerides. When a triglyceride molecule breaks down, it forms 3 fatty acid molecules (the main energy source of body fat), plus a glycerol molecule which can be combined with another to make glucose (via gluconeogenesis), and as a by-product, a ketone body. That is why this is called a ketogenic diet. The brain and the heart love ketones. I always feel pumped when my body is keto-adapted. That’s when I’m at my best.

Imagine this. If our “natural” diet was 55% to 60% carbohydrates, as our government tells us it should be, and we ran out of carbs to eat and couldn’t access our fat stores because of an elevated serum insulin, we’d run out of fuel. Our metabolism would slow down. We’d be sluggish and sleepy and hungry all the time. How then would we be able to hunt in this state? Without being lean. Without using fatty acids and ketones for fuel. Eating Low Carb is how our forebears survived. They had to be functioning at their best to hunt. Think about it.

Type 2 Diabetes, a Dietary Disease #368: My 2-Month, 20-Pound Challenge

I am in a unique situation at the moment. It is of my own making, and it is an opportunity to take sole responsibility for my actions. There are no confounding factors (“excuses”) or impediments to my success (or failure). It should be a good test of my intentions and my integrity in taking responsibility for the outcome.

I am home alone for the next 2 months. After driving my wife to Florida after Christmas, I flew to Bogotá to study Spanish for 3 weeks. While there I got some professional help translating a 16-page “Folleto” on the cause of Type 2 Diabetes and how best to treat it as a dietary disease. I then flew to Aruba to join my wife for a week to celebrate our 25^th anniversary, and then home to New York for the rest of the winter. Between one month in Bogotá and Aruba, I lost 2 pounds, but since returning to NY I have regained 4 in less than a week.

So, to fulfill a commitment I made to Megan Ramos, the Intensive Dietary Management Program Director and Clinical Educator in Jason Fung’s office in Toronto, and a Facebook friend, I am going to fast for 2 days a week. I’ve selected Tuesdays and Thursdays. On those days I will only take a 16-oz coffee in the morning with stevia and 1-oz of full cream; then, at night, 1 wine spritzer. Nothing else until the next day. I know this will not be difficult because I am not hungry now. I am apparently already sufficiently keto-adapted for my body to switch easily from whatever I eat (low-carb) to fat-burning to maintain energy balance and a high metabolic rate.

So I am now cooking for myself. This is something, guys, that will teach you how much you under appreciate that you spouse cooks for you every day, as mine does. Thus, on the remaining 5 days, I will cook supper twice, each time preparing food for 2 days. On the 5^th day, I will go out to dinner. That day will vary.

On non-fasting days, I will take the same coffee in the morning. Then, if I feel it necessary to eat something before supper, I have some stores in the pantry: 1) Brisling sardines in EVOO and 2) kippered herring in brine, both of which I love. The sardines, in terms of calories and satiating power, are a meal in themselves. The herring is more like a snack. I will use them as a light or late lunch, if I should sense any hunger at all, which is very unlikely. I will also keep on hand a few hard-boiled eggs from a local farmer if I feel the need for them.

Then for supper, my main dish will mostly be stove-top preparations of various cod recipes or a veal stew. The cod is wild caught in the North Atlantic and flash-frozen at sea. My recipes incorporate vegetables like onions, celery, cauliflower and fennel. I cook in coconut oil, butter or olive oil and add garlic, green olives, red pepper flakes, sometimes petite cubed canned tomatoes and always lots of salt and fresh ground black pepper.  As an alternate meal, I will sometimes make a veal kidney dish or a tripe en salsa roja preparation.

The veal is from another local farmer. For the stew, I use bacon, mushrooms, and onions and brown the veal cubes in coconut oil before baking. For the kidneys, I add mushrooms, onions and Marsala wine. Oh, and with each of these supper meals, I will drink 2 red-wine spritzers. I especially like a Spanish Rioja called El Coto.

Just to be clear about this: On my 5 non-fasting days each week, I will take only morning coffee, an occasional “big” lunch (a 3.75 oz. can of sardines + EVOO) or a “light” lunch ( a 3.5 oz can of kippered herring in brine) and the occasional hard-boiled egg or two. Then, supper with 2 wine spritzers. The nutrient breakdown is this:

Fasting days: Calories: 225kcal; Fat: 11g; Pro: 1g; Carbs: 4.75g; Alcohol: 15g

Non-fasting: Calories: 1000-1200kcal; Fat: 45-70g; Pro: 45-85g; Carbs: 15-30g; Alc: 30g 

I write this on Super Bowl Sunday at 248 pounds (FBG: 104mg/dl). I start tomorrow morning. This “manifesto” will first be published on February 19, two weeks hence. Anyone interested to know how I’m doing can use the comments section on either my blog (www.thenutritiondebate.com) or on Facebook, where I usually post. 

Type 2 Diabetes, a Dietary Disease #367: My Arm’s Length Perspective from Colombia

As I prepare to leave the beautiful city of Bogotá, after 3 weeks of studying Spanish, a few thoughts related to T2DM come to mind. This is a burgeoning city, growing leaps and bounds, transitioning from “a feudal society” (to quote the husband of my teacher) to a modern, invigorating, stimulating place. I loved it, and it’s exciting to see the changes coming about, but also shocking to see the stark contrasts. For grounding and perspective, the husband reminded me that women only gained the right to vote in 1957.

For me personally the most surprising discovery was that the brand new, modern apartment I rented, that has multiple USB connections in the kitchen and bedroom, has no central heat! Further, there is no hot water in the kitchen – only in the bathroom, with an electric in-line hot water heater for the sink and shower.

At first, I thought that this was a factor of the neighborhood (services are taxed by “estrado”). This method of taxing services by socio-economic status is designed to give preference (“subsidies”) to the less advantaged. Unfortunately, it also results in stagnation and immobility by stigmatizing the poorer neighborhoods.

Later, I discovered that the modern, well-designed apartment of my teacher and her husband (both PhD’s teaching at the National University) also has no central heating and no hot water in the kitchen. ¡Qué sorpresa! They live in an upscale neighborhood in the northern reaches of the city. The “no heat” explanation relates in part to the climate. Bogotá has a moderate climate year round. It is located close to the equator but at a very high elevation (8,675 feet or 2,644 meters), so temperatures are constant all year round. It never snows.

So this partially explains the central heating issue, but not the lack of kitchen hot water. “How do you wash dishes,” I asked the husband as he did them. “I scrub them well,” he said.  Does that give you perspective?

Type 2 diabetes is similarly just emerging from the dark ages. One hundred and fifty years ago type 2 diabetes was understood as a dietary disease (see my #1 with reference to Claude Bernard and William Banting). It was known as a disease of excessive consumption of carbohydrates and was treated by reducing carbohydrates in the diet. Then, in 1921, Frederick Banting (bizarrely, a distant relation!) discovered how to make insulin in the laboratory, and since then type 2 diabetes has been treated like type 1 diabetes, a disease of too little insulin.

When our insulin receptor cells resist the uptake of glucose, i.e. they express Insulin Resistance (IR), the pancreas produces more and more insulin until it eventually wears out. Doctors hasten this catastrophic failure of the pancreas by adding pharmaceuticals, like sulphonyureas (Micronase, glyburide, glipizide, et al.) to push the pancreas to exhaustion. Then, the doctors add injected insulin to the patient’s regimen. This medieval practice, not unlike “bleeding the patient,” is still the standard of treatment of the medical and government overseers in the United States.

But we are finally entering a Renaissance. Increasingly type 2 diabetes is being understood again as a disease of Insulin Resistance, resulting in too much insulin. The goal in treating type 2 diabetes should be not only to lower the glucose level in the blood (by diet instead of drugs), but also to lower the insulin level in the blood.

This will occur, and will only occur, when the glucose level lowers, because that is how the body “knows” that it needs to begin to burn fat (our triglycerides, in the form of body fat stored around the “trunk,” to maintain energy balance and a fully active metabolism. The body, including heart and brain, loves these fatty acids and the ketone bodies that are produced as a side effect of lipolysis (the catabolism of triglycerides to fatty acids).

And, for anyone interested, this is also best way to LOSE WEIGHT, easily and without ever feeling hungry.

Bogotá is rapidly transforming itself. ¡Ojalá que el mundo de los diabéticos se haga lo mismo! Y pronto.

Type 2 Diabetes, a Dietary Disease #366: Academy of Nutrition and Dietetics, a Secret Society

Surfing the web recently, I came across the Academy of Nutrition and Dietetics (AND). It turns out that for almost 100 years, until 2012, this organization was named the American Dietetic Association, unfortunately sharing the same acronym with the more recognized American Diabetes Association. With my interest piqued, and having a long-time interest in the subject, I delved into the membership categories. Here’s where I bumped into my first road block: membership is restricted to only RDNs and other dietetics’ professionals.

Still, being interested in their message, I clicked on their “Advocacy” button, then “Disease Treatment and Prevention” and finally “Diabetes Prevention Legislation.” I was pleased to see that the AND “has been actively involved in developing and generating support for five pieces of legislation that would help prevent type 2 diabetes.” Great, I thought, let’s have a look. Unfortunately, that too was not possible. To see more I’m told to “log-in or join.” But, as I am not eligible to join, and therefore can’t log in, the legislation for which they advocate will have to remain secret legislation. Only those indoctrinated in the Academy are eligible to view it.

So, I went to Wikipedia. I knew of course that many Wiki sites are written by the searched organization, but I thought I might learn something more about AND, as I would never be eligible to join. Here’s what I learned:

●      The Academy "maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise."^[20]

●      The Academy opposed mandated labeling of "trans fats" on food packaging.^[28]

●     The Academy has given low ratings to the “high-protein, low-carb” diet known as the Atkins Diet, insisting that the diet is "unhealthy and the weight loss is temporary."^[29]

●     The Academy maintains that carbohydrates are not responsible for weight gain any more than other calories^.[30]

Okay, I no longer needed to see the five pieces of legislation that AND has developed. I know where they’re coming from. But why? What motivates them to be so obtuse? And so backward? I needed to look further.

Here’s what Wikipedia says: “To help better communications with the US government, the Academy of Nutrition and Dietetics has offices in Washington, DC. They also operate their own political action committee.^[13] The Academy spent $5.8 million lobbying at the state and national level from 2000–2010.^[46]

And “A 1985 report noted the Academy has supported licensing for dispensing nutritional advice,^[47]” and “In addition… [has] support[ed] legislation regulating the professional nutrition field in [various] states.”

And finally, the coup de grace: “A 1995 report noted the Academy received funding from companies like McDonald’s, PepsiCo, The Coca-Cola Company, Sara Lee, Abbott Nutrition, General Mills, Kellogg’s, Mars, McNeil Nutritionals, SOYJOY, Truvia, Unilever, and The Sugar Association as corporate sponsorships.

“The Academy also partners with ConAgra Foods, which produces Orville Redenbacker, Slim Jims, Hunt’s Ketchup, SnackPacks, and Hebrew National hot dogs, to maintain the American Dietetic Association/ConAgra Foods, ‘Home Food Safety...It's in Your Hands’ program.” Additionally, “the Academy earns revenue from corporations by selling space at its booth during conventions, doing this for soft drinks and candy makers.”

Wikipedia continues with this trenchant comment from nutrition expert Marion Nestle. She “opined that she believed that as long as the AND partners with the makers of food and beverage products, ‘Its opinions about diet and health will never be believed [to be] independent.’”^[54] 

And, “Public health lawyer Michele Simon, who researches and writes about the food industry and food politics, has voiced similar concerns stating, ‘AND [is] deeply embedded with the food industry, and often communicate[s] messaging that is industry friendly.’"^[60] 

I guess it’s a good thing for both of us (AND and me) that they won’t let me join this lucrative business. I would just “rock the boat” or “upset the (rotten) apple cart,” to use a more apt metaphor.

Type 2 Diabetes, a Dietary Disease #365: The Dual Pincers of Clinical Practice Guidelines

This article in the Journal of the American Board of Family Medicine begins, “Clinical practice guidelines abound. The recommendations contained in these guidelines are used not only to make decisions about the care of individual patients but also as practice standards to rate physician ‘quality.’” Did you know that? I have for awhile, and it concerns me. I first became aware of it during the funding cuts in Medicare (+/- $750 billion) during the “negotiations” leading up to the passage of the “Affordable Care Act” (ACA, aka Obamacare).

The Journal article continues, “Thus there is an inevitable aspect of guideline development that makes it subject to value judgments and can be unconsciously colored by intellectual, professional, or financial conflicts of interest.” These include biases such as “decisions colored by tunnel vision (job conditioning), ‘seeing what you want to see’ (confirmation bias), decisions limited to the tools at hand (Maslow’s hammer), or other inclinations that can affect judgment.” That last one especially concerns me. Why? Medicare Payment Reform.

We have all become aware of the movement towards Electronic Health Records (EHR). But did you know that there are financial incentives and disincentives for physician compliance? The EHR program, called Meaningful Use (MU), is now in the process of being itself re-reformed. According to a blog post from Impact Advisors, posted before the final rule was issued, “providers simply wanted to ‘check the box’ in order to reach MU thresholds (and thus avoid ‘adjustments,’ i.e., penalties), foregoing the larger opportunity to improve care.”

EHR was Part 1 of a larger reform program of the Center for Medicare and Medicaid Services (CMS). It is still in place, but Part 2, described as “share data” and Part 3, “improve outcomes,” are now part of a new Medicare Payment program designed to overcome the “noted weaknesses of MU.” Part 1 will be transformed and phased in by stages starting in 2017. Parts 2 and 3, now the Merit-Based Incentive Payment System (MIPS), is part of the Medicare Access and CHIP Reauthorization Act (MACRA) and implementation begins in 2019.

Now, according to an AMA email “alert” that I received last fall, CMS has issued its final MACRA rule, detailing the new Merit-Based Incentive Payment System, now called the Quality Payment Program (QPP). In the email, AMA President Andrew Gurman thanked CMS Acting Administrator Andrew Slavitt for being a “sincere partner” during the process. Gurman was very pleased at the influence the AMA’s comments had that “will allow for a reasonably paced progression into the program so that physician practices can learn and adjust…”

He said, “The key elements of the proposed rule that CMS changed based on our recommendations are:”

●     Physicians would not have to report in all four MIPS categories to avoid a negative payment adjustment. Instead, the only physicians who “will experience a negative 4% penalty in 2019 [increasing in steps to 9% by 2022] will be those who choose to report no data.”

●     Participating in one of 4 options under “Pick Your Pace” will “help the physician avoid penalties.” At the very least if (s)he “chooses to report for only one patient on just one quality measure, one improvement activity, or the 4 required Advancing Care information (ACI) measures, [(s)he] will avoid a negative payment adjustment.”

●     The final rule established a 90-day reporting period, “a significant change over the proposed rule, full calendar-year requirement.” If the physician reports for at least 90 continuous days in 2017, (s)he will be eligible for a positive payment adjustment. This adjustment allows the physician to start later, to have more time to prepare.

●     A reduction in the program-wide reporting burden from 11 reporting measures to 4 in 2017 and 5 thereafter.

●     “An increase in the low-volume threshold to qualify for exemption from QPP participation.” CMS increased the threshold from $10k to $30k in Medicare payments, but kept the 100 Medicare patients per year limitation. So, know that your physician has been incentivized to not accept new Medicare patients, and to drop the old ones.

Does this give you a sense of why your relationship with your doctor has changed in recent years? I started this column feeling a bit angry at my doctor. I end it feeling sorry for him. Look what’s happening to Medicare!

Type 2 Diabetes, a Dietary Disease #364: “Prediabetes, in other words, is Diabetes”

This title is in quotes because…I think I cribbed it from Kelley Pounds, an RN, CDE, blogger and diabetes educator whose writings I always find interesting and informative. But, alas, I can’t link to it here because I can’t find that title in her Table of Contents. So, a hat tip to Kelley Pounds and this link to her home page.

The point of the title is that Kelley, and I and many other “activists,” and of late, some researchers, are urging the public health establishment in the U. S. and world-wide to take a hard look at the current Standard of Practice for defining Prediabetes and consider lowering or re-defining it. The implications of doing this are momentous; but likewise, if this is not done, the outcomes will be catastrophic. Consider this recent revelation from the CDC: “Life expectancy for the U. S. population in 2015 was 78.8 years, a decrease of 0.1 years from 2014.” That’s the first DECREASE IN LIFE EXPECTANCY in the U.S. since 1999. Think it’s related to our lifestyle?

A ton of evidence associates LIFESTYLE DISEASES with METABOLIC SYNDROME, the major outcomes of which are Type 2 Diabetes and heart disease. That’s why BETTER STANDARDS are needed to address this scourge.

THE LIFESTYLE DISEASES

Cardiovascular Disease (CVD), Coronary Heart Disease (CHD), Stroke, Type 2 Diabetes Mellitus (T2DM), Non-alcoholic Fatty Liver Disease (NAFLD), Alzheimer’s Disease, aka Type 3 Diabetes, and even Erectile Dysfunction. Also several types of cancer; A large population study, in “Diabetes Care,” shows that “the relative risks of various cancers imparted by diabetes are greatest (about twofold or higher) for cancers of the liver, pancreas, and endometrium, and lesser (about 1.2–1.5 fold) for cancers of the colon and rectum, breast, and bladder.”

METABOLIC SYNDROME

A WebMD stub puts it succinctly: “Metabolic syndrome is a collection of symptoms that can lead to diabetes and heart disease. The good news is that metabolic syndrome can be controlled, largely with changes to your lifestyle.” The five related symptoms, first introduced six years ago to my readers here, and updated here, and then here and here, are: a Body Mass Index (BMI) ≥30, or large waist circumference (men ≥40 inches, women ≥35 inches); elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, and/or use of medications for hypertension) and elevated fasting glucose (≥100 mg/dl, and/or the use of medications for hyperglycemia).

THE BETTER STANDARDS

In the U.S. the longstanding criteria for a clinical diagnosis of Type 2 Diabetes Mellitus (T2DM) was two consecutive office visits with a fasting blood sugar ≥140mg/dl (7.8mmol/L). In 1997 that standard was lowered to ≥126mg/dl (7.0mmol/L). In 2002 a definition for Pre-Diabetes was added: an IFG ≥ 100 to 125mg/dl (5.6 to 6.9mmol/L) or an IGT of 140 to 199mg/dl (7.8 to 11.0 mmol/L) two hours after a 75 gram glucose challenge. The WHO uses a higher IFG threshold: ≥110to 125mg/dl (6.1 to 6.9mmol/L). Later, in the U. S., the HbA1c measurement was added to supplement or in some cases now to supplant the IFG. In the U. S., an HbA1c between 5.7% and 6.4% is considered Pre-Diabetic and ≥6.5% Type 2 Diabetes. Elsewhere in the world, Pre-Diabetes is defined as an “A1c” ratio between 49 and 56mmol/mol and Type 2 Diabetes as ≥58mmol/mol.

For years leading research scientists like Ralph A. DeFronzo and pioneering clinicians like Richard K. Bernstein have called for a lower standard for the diagnosis of incipient Type 2 Diabetes. These men are leading diabetes specialists who have devoted their lives to combating this disease. They are both superstars.

Now, as I reported in #362, the BMJ (British Medical Journal) has just published a Chinese meta-analysis done on 1,611,339 people. The lead researcher’s takeaway: “Effective intervention in prediabetes is not just for prevention of diabetes, but also cardiovascular diseases.” The majordomos are starting to connect the dots.

WHAT HAS TO BE DONE?

Type 2 Diabetes has to be redefined, as DeFronzo and Bernstein would say – indeed have said: “Prediabetes, in other words, is Type 2 Diabetes.”

And at the clinical level today, physicians, using the current standard, have to not treat Prediabetes with temporizing measures, e.g., “We’ll have to monitor your blood sugar” (read: to watch your Insulin Resistance worsen as you eat the Standard American Diet. Clinicians need to tell you: “You are Carbohydrate Intolerant.”