The Toxic Myth that Kills and Cripples People with Type 2 Diabetes

The single most dangerous idea you are likely to encounter as you begin your struggle to live a healthy life with diabetes is the belief that science has proven, beyond a doubt, that no matter what you do, your type 2 diabetes will get worse.

Unfortunately, your doctor probably believes it. Though he may give lip service to the idea that you can control your disease through diet, exercise, and drugs, he probably believes that nothing you can do will make much difference in your long-term outcome. This is why doctors are not likely to urge you to take a proactive approach to managing your disease but merely write you prescriptions for drugs that, at best, do a mediocre job of controlling your blood sugars.

Why doctors believe this toxic myth

They've Seen it in their Practice

Doctors will tell you that they've treated lots of patients with type 2 diabetes and that few, if any, of their patients can control their diabetes with diet. They'll say that their patients cannot lose weight, and that even with good control they end up with complications.

UKPDS "Proved" People with Good Control Deteriorate

Doctors will also tell you that a large-scale study, the UKPDS (United Kingdom Prospective Diabetes Study) proved that even with good control patients with Type 2 diabetes inevitably deteriorated over time.

The UKPDS, they'll tell you, found that the Hba1c test results of patients with good control gradually worsened every year. Not only that, but many doctors also believe that UKPDS really showed that good control can only make a small difference in the rate of complications, and that as a result lots of people with good control still get complications.

That last bit isn't just me being paranoid. You can read it in the words of Dr. Roy Taylor, a professor of medicine and metabolism at the University of Newcastle upon Tyne. His words appear in a slide presentation he gave to other medical specialists. This talk was presented by the Annenberg Center for Health Sciences and published by Medscape December 22, 2003 as an online course offering good for earning one continuing medical education (CME) credit. Read it HERE.

In his presentation, Dr. Taylor points to a chart taken from UKPDS data titled "Newly Diagnosed Type 2 Diabetic Subjects Showing Progression of Retinopathy." He explains, "These data are usually presented as showing a wonderful difference between the groups, [those controlling their blood sugar and those not] 37% relative risk reduction. But take another look. This slope is unfortunate. This slope is almost equally unfortunate for the individuals concerned. Although intensive therapy in type 2 diabetes over 15 years makes a difference, it's not a staggering difference."

Later when he discusses the UKPDS findings about the progression of nerve damage he says "the abnormal nerve function continues to progress inexorably"

When discussing early signs of kidney damage, he delivers the same message. "Intensive therapy [i.e. blood sugar control] does not seem to be able to stop this."

So it is no surprise when Doctor Taylor concludes that controlling blood sugar in type 2 diabetes may make a small difference "but not such a huge difference that you would want to go out of your way as a patient to achieve it, perhaps, if you were shown this graph and told that over 15 years of intensive therapy you would be not much different compared with a "laissez faire" approach."

Abandon Hope All Ye Who Enter Here?

If Dr.Taylor is right, it would make sense to take a fatalistic attitude towards your diabetes. If a diagnosis of diabetes sentences you to a life haunted by nasty complications and premature death why put yourself through all the miseries of a life-long diet and the struggle to watch what you eat every day? If there is nothing you can do, it is rational behavior to shift your energy elsewhere and enjoy life--including the foods you love--while you can.
But it is not true. Doctor Taylor and his peers have missed one extremely important point in considering the UKPDS data.

"Good Control" in UKPDS and Common Medical Practice is Really Mediocre Control

Though doctors do, in fact, see patients with "good control" go on to develop complications, and though it is true that the UKPDS did show that patients with "good control" deteriorated over time, "good control" in UKPDS and in most medical practices is defined only to mean that patients registered Hba1c test values under 7.0%.

The Hba1c test value of 7.0% which doctors and UKPDS have defined as "good control" for people with Type 2 diabetes, is the test value which turns out to correspond to an average blood sugar of 172 mg/dl (9.6 mmol/L).

This blood sugar level is considerably higher than the level at which neuropathy begins and at which lab research has shown that irreversible beta cell damage occurs--which you'll remember was 140 mg/dl (7.8 mmol/L).

UKPDS Participants were Probably Spiking Way Above 200 mg/dl (11 mmol/L)

But even more important, the HbA1c test result reflects the average blood sugar sustained over the past several months. And because it is an average, it does not distinguish between the person whose average blood sugar level of 172 mg/dl was achieved by maintaining their blood sugar at a steady 172 mg/dl throughout the day and the person whose blood sugar surged up to 300 mg/dl after eating high carbohydrate meals and then plummeted to 70 mg/dl as insulin kicked in, insulin that was injected or stimulated by the sulfonylurea drugs that force the beta-cells to produce more insulin.

It is very likely that for most UKPDS participants--and for most of your doctors' patients who have been following the standard dieticians' advice to eat a high carbohydrate, low fat diet--the latter scenario was what went on. They spent hours with their blood sugars over 300 mg/dl but these highs were balanced by d periods of insulin-stimulated low blood sugar.

That is likely because the participants in the UKPDS were using sulfonylurea drugs and insulin to achieve their blood sugar targets. The standard dietary advice given to patients on insulin and sulfonylurea drugs is to eat a very high carbohydrate diet, in order to avoid the very real possibility of dangerous and even fatal episodes of hypoglycemia. So the patients in the UKPDS probably did have blood sugar that was rollercoastering up and down all day.

UKPDS only Proved that An Average Blood sugar of 172 mg/dl is Toxic!

So when all is said and done, the UKPDS really just proved that patients on drug regimens that allow their blood sugars to rise high enough to produce glucotoxicity for many hours each day will continue to experience complications and that these patients will also see their blood sugar control deteriorate over time as their remaining beta cells succumb to glucotoxicity.

Think of it this way: How would you feel if your doctor said that most patients who quit smoking develop lung cancer--while defining "quit smoking" as "Smoke only 10 cigarettes a day?"

That's exactly the same thing going on here, because the blood sugar targets doctors are prescribing for their patients are way over the level where good research has proven that organs are irreparably damaged. (For more on this subject read At What Blood Sugar Levels Does Damage Occur

The Hba1c that Corresponds to Truly Normal Blood Sugar Levels

While your doctor might call a value just south of 7% "good control", the blood sugar level that corresponds to what truly normal people experience is just under 5.0%. Another study, EPIC-Norfolk, found that the risk of death from heart attack for all people, not just those with diabetes, was half as much when Hba1c test results were below 5.0% than when they were above it. However, the risk of all other diabetic complications remains very low as long as the Hba1c remains under 6.0%, which is the range most labs assign to "normal."

Another Less-Known Study Has more Impressive Results then UKPDS

As we mentioned earlier, the Hba1c is only an average. It ignores the very important question of how high blood sugars are spiking after meals. So what happens if instead of measuring only the HbA1c, you measure post-meal blood sugars and attempt to control how high they go?

A ground-breaking Japanese study answers this question definitively. The researchers in this study, conducted in Kumamoto Japan, found that by using post-meal blood sugar targets, they were able to keep the Hba1cs of participants in their study stable over its entire 6 year course. Instead of the "inevitable decline" in blood sugar control we saw in the UKPDS, these people with type 2 diabetes saw no deterioration at all.

Not only that, but over the course of the study, the incidence of retinopathy, kidney damage, and nerve damage, were dramatically lower in the group that maintained tight control of their post-meal blood sugars. In fact, the intensive intervention group as a whole saw slight improvements in the qualities of their nerve damage by the end of the study rather than the deterioration seen in all other studies.

Motoaki Shichiri, Hideki Kishikawa, Yasuo Ohkubo, , Nakayasu Wake, Long-Term Results of the Kumamoto Study on Optimal diabetes Control in Type 2 Diabetic Patients. Diabetes Care Volume 23 Supplement 2, 2000

http://journal.diabetes.org/diabetescare/FullText/Supplements/DiabetesCare/Supplement400/B21.asp

What makes this study so interesting is that the average HbA1c test results of the people in the Kumamoto "intensive intervention group" was identical to the average HbA1c of the people in the UKPDS at the beginning of the study. What was different was that the blood sugar control strategy the Kumamoto study used focussed on keeping post-meal blood sugars lower.

While the average blood sugar was the same for both groups, the Kumamoto group NEVER let their blood sugar hover at the high levels that the UKPDS study participants reached.

This is extremely good news for people who do not wish to succumb to inevitable decline. And, in fact, it is even better news than the foregoing would suggest, because the patients in the Kumamoto study were controlling their blood sugar using an intensive insulin regimen which required that they keep their blood sugars higher than normal to avoid the danger of severe low blood sugars. So the people in the "intensive intervention" group whose results were so impressive compared to the "intensive intervention" group in the UKPDS still had HbA1cs near 7.0% and post meal blood sugars that rose to 180 mg/dl after meals.

A 2006 Study Proves Not All Type 2s Deteriorate and Some Even Improve

A long-term study of people with Type 2 diabetes run at the Mayo Clinic measured the C-peptide levels of people with Type 2 diabetes every two years over a period of twelve years. Here's what they found: "Insulin secretion . . . declined with increasing duration of diabetes in approximately half of the patients but either increased or remained essentially constant over time in the other half.... These data indicate that although a decrease in insulin secretion over time is characteristic of type 2 diabetes mellitus, it is not inevitable."

What screams out of the page here is this: Why didn't they study the people whose insulin production didn't decline or improved and find out a bit more about them? Were they better controlled? Eating a certain diet? And was the rise in insulin due to increased insulin resistance or to decreased blood sugar stress. Without this information, the study is not as informative as it might be. But it certainly answers the question "Do I have to Deteriorate" with a resounding "No!"

Effects of Duration of Type 2 Diabetes Mellitus on Insulin Secretion. Farhad Zangeneh, Puneet S. Arora, Peter J. Dyck, Lynn Bekris, Ake Lernmark, Sara J. Achenbach, Ann L. Oberg, Robert A. Rizza.Endocr Pract. 2006;12:388-393

http://aace.metapress.com/(xkupqpuafvs0h355wveehh45)/app/home/contribution.asp?
referrer=parent&backto=issue,6,23;journal,4,81;linkingpublicationresults,1:300404,1

What if you Keep Post-Meal Blood Sugar Spikes Below 140 mg/dl?

Just keeping blood sugar from spiking over 180 mg/dl made a huge difference in the incidence of complications and even improved neuropathy. But we know that neuropathy starts when blood sugars spike over 140 mg/dl. So the question that is still unanswered by this study is this: what would happen to people with type 2 diabetes who were able to keep their blood sugars under 140 mg/dl--the level at which it is believed that serious damage begins?

Unfortunately, you won't find a study that answers this question because most doctors believe that it is impossible for people with type 2 diabetes to achieve that level of control.

And it is impossible if patients attempt it while eating a high carbohydrate diet. But plenty of people online who a follow a lower carbohydrate diet have found that they are able to prevent their post-meal blood sugars from rising over 140 mg/dl, without injecting any insulin.

The Key is the Strategy Known as "Eating to Your Meter"

The way that people with type 2 diabetes are able to reach truly good control is described here:

http://www.alt-support-diabetes.org/Newly%20Diagnosed.htm.

This strategy is simple. You use your blood sugar meter to test your blood after every meal and eliminate from your diet the foods that raise your blood sugar over 140 mg/dl at one hour and 120 mg/dl at 2 hours.

This strategy has worked for many people whose Hba1cs were as high as 13.0% at diagnosis who were able to bring them down to the 5% range within a few months. I've maintained an Hba1c in the 5% range for most of the past 7 years.

Some people can achieve this level of control with dietary control alone. Others find that it helps to take Metformin and/or Avandia/Actos. Most people who pursue this strategy avoid the sulfonylurea drugs because they force the pancreas to overproduce insulin which can cause dangerous low blood sugar attacks. Metformin and Avandia/Actos usually do not cause lows.

Where are the Studies of Long-Term Consequences of Truly Good Control?

There are none. To date there is no study of people with type 2 diabetes who have consistently achieved post-meal blood sugar levels under 140 mg/dl. In fact, most studies besides the Kumamoto study have completely ignored the question of what post-meal values participants achieved.

Because we only have studies that show that patients who maintain blood sugars in the toxic range well above 140 mg/dl and who spike over 200 mg/dl daily inevitably deteriorate, it is premature to conclude that all patients with type 2 diabetes inevitably deteriorate.

Don't Settle for Mediocrity No Matter What Your Doctor Advises

Doctors have indeed seen thousands of patients with type 2 diabetes fail to lose weight--because they put them on low fat/high carbohydrate diets that don't work for people with diabetes. They've seen them develop complications with good control, only because "good control" meant spiking over 200 mg/dl after every high carbohydrate meal.

But in the past couple years, since low carb dieting became more popular, doctors are also seeing a new kind of patient. This is the patient who loses a lot of weight with a low carb diet and attains hitherto impossible blood sugar control--while bringing down cardiac risk factors like high cholesterol and blood pressure. Studies are only now beginning on the long-term health impact of these changes. Unfortunately, it will take a decade or more until the results are in.

What do you Have to Lose?

If you pursue a lowered carbohydrate, "Eat to your Meter", regimen and keep your blood sugars under 140 mg/dl at all times, and a decade hence studies show that even with excellent control and normal blood sugar levels patients still deteriorate, all that you'll have lost is a lot of carbohydrate-laden meals (and possibly some weight.) But if you settle for that 7.0% Hba1c control your doctor recommends, with its post-meal spikes over 200 mg/dl, and in 10 years the studies show that keeping blood sugar under 140 mg/dl at all times prevents most diabetic complications, you may have paid for your choice with bleeding retinas, failing kidneys, and gangrenous toes.

Which approach you choose is up to you, but remember, it's not your doctor's retina, kidneys, and toes that are at risk here.