If you need any more motivation to pursue normal blood sugars consider this:

Heart attack risk more than doubles at blood sugar levels considered to be "pre-diabetic"

Sadly, the same doctors who put you on a statin when your lipids are mildly elevated completely ignore the much more significant risk that are posed by average blood sugars over 87 mg/dl (4.8 mmol/l) the truly normal range for blood sugar.

The reason why has to do with drug company profits: All that the expensive statin drugs do is reduce total cholesterol by reducing LDL. So to sell them, drug companies have sold doctors and the public on the idea that they can prevent heart attacks by lowering LDL and total cholesterol--even though this is far from what the data actually prove. In fact, at least 1/3 and possibly a half of all people who have a first heart attack have normal cholesterol, and giving statins to people who have not had heart attacks does not decrease their incidence of heart attacks.

Fortunately, there is one measurement that does tell you what your risk of heart attack might be, and it works for everyone, not just those diagnosed with diabetes: The A1c.

The A1c is a blood test that measures how much sugar is permanently bonded to a hemoglobin protein found in your red blood cells. These red blood cells live an average of 3 months, so the amount of sugar that is bonded to them is a rough measurement of often your cells have been exposed to high blood sugar over this period. (If you are anemic or have abnormally long or short-lived hemoglobin cells, the A1c may not give an accurate measurement of your long-term blood sugar control).

Why Cholesterol and LDL Poorly Predict Heart Attack Risk

You would never know it from the statin ads, but half of all people who have heart attacks have no known risk factors--which means, among other things, that they have completely normal cholesterol.


Am J Crit Care. 1998 May;7(3):240-4 Fifty percent of patients with coronary artery disease do not have any of the conventional risk factors. Futterman LG, Lemberg L.

Among that half that has high cholesterol, the Framingham heart study data shows clearly that it isn't LDL or total cholesterol that predict heart attack.


Atherosclerosis. 1996 Jul;124 Suppl:S1-9. Lipids, risk factors and ischaemic heart disease. Castelli WP. Framingham Cardiovascular Institute, MA 01701-9167, USA.

Here's an except from that study:

Two simple tests for determining plasma lipid levels can be used to identify those individuals with an atherogenic lipid profile and who are, therefore, at increased risk for CVD. Firstly, the ratio of total cholesterol to high density cholesterol (HDL cholesterol) should be determined, followed by measurement of plasma triglyceride concentrations.

This states clearly that the most important parts of cholesterol, which are the only cholesterol measurements shown to be mildly associated with heart attack and thus useful in prediction are:

• The ratio of Total Cholesterol/HDL, which should be under 3
• Triglycerides which should be under 100

What Improves The Framingham Lipid Risk Factors?

What raises triglycerides is dietary carbohydrate. The more carbs you eat, especially those that circulate in your blood stream as high blood sugar, the higher your triglycerides will be. To get a healthy level of triglycerides, you need to lower your blood sugar, which for most of us means cutting the carbs.

Metformin, which has been shown to have a cardioprotective effect will also significantly lower triglycerides


Furthermore, a study published in Sept, 2007 found that even with low LDL it is the level of HDL (not affected by statins) that predicts heart attack risk.

New England Journal of Medicine: HDL Cholesterol, Very Low Levels of LDL Cholesterol, and Cardiovascular Events

What raises HDL? Cutting carbohydrates out of your diet.

What does all this suggest? That the significant cholesterol fractions--if they mean anything, risk-wise--are those that point to high blood sugar.

Triglicerides in Heart Muscle may Be At Fault

Diabetes in Control reported on a study published in the September 4, 2007 issue of Circulation comes up with a novel observation that may further bolster the idea that it is high post-meal blood sugars that cause heart attacks in people with diabetes. The study found that "lipid overstorage in human cardiac myocytes is an early manifestation in the pathogenesis of type 2 diabetes mellitus." This means that lipds are overstored in heart muscle very early in the progress of diabetes.

The specific lipid stored is triglyceride, which is the form of fat that the body creates out of glucose when blood sugar is high.This appears to occur at the blood sugar levels only slightly over normal--those associated with "impaired glucose tolerance" Cutting back carbohydrates is a very effective way of normalizging those blood sugars and it is also well known to lower the concentration of triglycerides in the bloodstream, It is possible that lowering blood sugar to normal prevents the deposit of fat molecules in the hear and may explain why A1c correlates so closely with heart attack risk with or without a diabetes diagnosis.

Cardiac steatosis in diabetes mellitus: a 1H-magnetic resonance spectroscopy study.McGavock JM, Lingvay I, Zib I, Tillery T, Salas N, Unger R, Levine BD, Raskin P, Victor RG, Szczepaniak LS. Circulation. 2007 Sep 4;116(10):1170-5. Epub 2007 Aug 13.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=17698735

A new study links post meal blood sugars to artery thickening

An Italian team published a study in January of 2008 where they report that over five years the increase in the thickness of the carotid artery correlated directly with the amount that blood sugars rose after meals in people with diabetes measuring their blood sugar at home.

They found dangerously high rises in 95% of people with diabetes in their study, probably because they were encouraged to eat the extremely high carbohydrate ADA-recommended diet and attempt to counter the post-meal peaks with oral drugs which the study found, did not control the peaks.

http://jcem.endojournals.org/cgi/content/abstract/jc.2007-2000v1
Postmeal glucose peaks at home associate with carotid intima-media thickness in type 2 diabetes
Katherine Esposito, Miryam Ciotola, Diego Carleo, Bruno Schisano, Luigi Sardelli, Domenico Di Tommaso, Lucio Misso, Franco Saccomanno, Antonio Ceriello, and Dario Giugliano*
J Clin Endo doi:10.1210/jc.2007-2000

A1c Accurately Predicts Heart Attack Risk

This was discovered a few years ago in a large-scale study called EPIC-Norfolk. What's particularly valuable about this study is that they weren't looking for causes of heart disease. They were studying cancer and they were looking at blood sugar because of the belief that it might be related to cancer incidence, which turned out not to be the case. The finding that A1c predicted heart disease in people with supposedly normal blood sugar was a shocker.


Annals of Internal Medicine, 9/21/2004, Vol 141, no 6, 413-420 Association of Hemoglobin A1c with Cardiovascular Disease and Mortality in Adults: The European Prospective Investigation into Cancer in Norfolk Kay-Tee Khaw, MBBChir FRCP; Nicholas Wareham, MBBS, FRCP; Sheila Bingham, PhD; Robert Luben, BSc; Ailsa Welch, BSc; and Nicholas Day, PhD

Here's the summary from that paper's conclusions:

In men and women, the relationship between hemoglobin A1c and cardiovascular disease (806 events) and between hemoglobin A1c and all-cause mortality (521 deaths) was continuous and significant throughout the whole distribution. The relationship was apparent in persons without known diabetes. Persons with hemoglobin A1c concentrations less than 5% had the lowest rates of cardiovascular disease and mortality. An increase in hemoglobin A1c of 1 percentage point was associated with a relative risk for death from any cause of 1.24 (95% CI, 1.14 to 1.34; P < 0.001) in men and with a relative risk of 1.28 (CI, 1.06 to 1.32; P < 0.001) in women. These relative risks were independent of age, body mass index, waist-to-hip ratio, systolic blood pressure, serum cholesterol concentration, cigarette smoking, and history of cardiovascular disease.


Another study which drew similar conclusions discovered an even tighter correlation between A1c and heart disease risk that began as A1c rose above 4.6%, a level that corresponds to a blood sugar level of 86 mg/dl (4.8 mmol/l)!


Arch Intern Med. 2005;165:1910-1916. Glycemic Control and Coronary Heart Disease Risk in Persons With and Without Diabetes. The Atherosclerosis Risk in Communities Study. Elizabeth Selvin, PhD, MPH; Josef Coresh, MD, PhD; Sherita H. Golden, MD, MHS; Frederick L. Brancati, MD, MHS; Aaron R. Folsom, MD; Michael W. Steffes, MD, PhD


To quote what that study found:

In nondiabetic adults, HbA1c level was not related to CHD risk below a level of 4.6% but was significantly related to risk above that level (P<.001). In diabetic adults, the risk of CHD increased throughout the range of HbA1c levels. In the adjusted model, the Risk Ratio of CHD for a 1 percentage point increase in HbA1c level was 2.36 (95% CI, 1.43-3.90) in persons without diabetes but with an HbA1c level greater than 4.6%. In diabetic adults, the Risk Ratio was 1.14 (95% CI, 1.07-1.21) per 1 percentage point increase in HbA1c across the full range of HbA1c values.


In short, it isn't whether you have diabetes that decides your risk, it's whether you have abnormal blood sugars, and the more abnormal, the more the risk. But "abnormal" blood sugars are those that doctors now treat as normal!

A study presented by Dr Esther van 't Riet at the EASD meeting in Sept, 2007, confirmed that even for people without diabetes A1c closely matches heart attack risk.

This study turned up information that needs further discussion. It found that though A1c matched cardiac risk, 2 hour oral glucose tolerance test (OGTT) results did not. I have proposed a common sense explanation for why that might be HERE. In brief my belief is that the OGTT--as anyone who has taken one knows--because it uses a huge dose of pure glucose that all hits the bloodstream within fifteen minutes does NOT mimic the action of high carbohydrate food on our blood sugar. When people have a blood sugar response in the 5-6% A1c range, 75 grams of glucose will produce a very high reading at 1 hour and then the blood sugar drops back very swiftly giving a normal or mildly impaired reading at 2 hours--the time used in this study to compare OGTT results with heart attack risk.

In real life, however, eating 75 grams of carbs in a meal of slower digesting food will produce--in the same person who got the moderate OGTT result--2-3 hours of damagingly high blood sugars which are what causes the heart disease.

Given that people with 5% A1cs often see peaks at one hour after eating which drop dramatically at 2 hours, I speculate that looking at post-meal (not OGTT) blood sugar values in people with 5% A1cs using a high carb meal would show a correlation between 1 hour values and heart attack risk.

Here is a summary of the EASD report from Diabetes in Control:
Even in nondiabetics, increased HbA1c levels are associated with a significantly increased risk of nonfatal cardiovascular disease after other cardiovascular risk factors are accounted for.

Can Normalizing A1c Reduce Cardiac Risk?

It sure looks like it! Since the relationship between blood sugar level and cardiac risk is so clear cut it looks like people with diabetes don't get heart attacks because diabetes does something special to the heart. Instead, it looks like they get heart attacks because doctors tell them to maintain A1c levels near 7%--A1cs that are 2.4 percentage points above that 4.6% normal.

Something about having abnormally blood sugars, even ones that are considered normal by today's doctors, is what kills!

What Can You Do To Reduce Risk?

Your first step should be to stop worrying about total cholesterol and LDL, instead look at your triglycerides and Total/HDL ratio. If they are high, you know you need to cut back on carbohydrates.

Then ask your doctor to do an A1c test for you. It is not an expensive test and you can do it nonfasting. Some doctors even do it in their offices.

If your A1c is over 4.6%, it's time to start measuring your blood sugar, cutting down on carbohydrate, and getting back to the normal levels that will lower your risk.

If you are diabetic, you probably know your A1c already. But you've probably been told that a much-too-high A1c is "fine." The data above should make it clear it is fine only if you don't care about dropping dead from what is the number one killer of people with diabetes--heart attack.

No matter how rotten your A1c right now, you can get it very close to normal using a combination of cutting the carbs, using metformin and, if you still can't get to normal levels, using an insulin regimen that controls post-meal blood sugars.

New Data: Blood Sugar Post Meal Spikes Correlate with Heart Disease in NON-Diabetic People Too!

Though heart disease is more common among people with diabetes, it is a major killer of supposedly "normal" people too.

Now an intriguing study has found a strong correllation between post-challenge blood sugar (i.e. the blood sugar spike you get for an hour or two after eating carbs) and heart disease in a group of "normal" women. While there was no relationship between their fasting blood sugars and the rate at which they developed coronary artery disease over a period of about 3.5 years, there was a strong relationship between their scores on a glucose tolerance test and the degree to which they developed coronary artery disease.

Post-challenge glucose predicts coronary atherosclerotic progression in non-diabetic, post-menopausal women P. B. Mellen, V. Bittner, D. M. Herrington (2007)
Diabetic Medicine 24 (10), 1156-1159.

If you do have diabetes, what does this mean for you? It means that the best thing you can do to avoid getting heart disease or to slow its development if you are in the early stages is to prevent your post-meal blood sugars from rising over normal limits. That means doing what you can to keep your blood sugar under 140 mg/dl (7.8 mmol/L) after every meal. To do this, you will have to cut down on carbohydrates. No drug will do this for you.

Also, this finding should encourage you to limit the carbs everyone in your family eats, because it's almost certain some of the supposedly "normal" people around you are getting the high post-meal high blood sugars that produce heart disease though they are not getting diagnosed thanks to their normal fasting blood sugars. The fasting blood sugar test is the only test most American doctors use to evaluate blood sugar health.

NOTE: When Your A1c May Be Inaccurate

Doctors have a touching faith that the A1c reflects your blood sugar control. Unfortunately, it is misplaced.

The A1c will not reflect your actual blood sugars if:

1. You have anemia. When you are anemic the A1c will be much lower than the value corresponding to the actual concentrations of glucose in your bloodstream



2. If you are on dialysis. If you are on dialysis your A1c will also be much lower than the value that reflects your actual blood sugars.



3. If you have very good control. With excellent control, your red blood cells may live much longer than normal, so they will collect more glucose simply because they've had longer to do it. This may make your A1c higher than the value that reflects your actual glucose control.



4. If you have certain genetic variants of the red blood cell. This often leads to a much lower than expected A1c.

You should never rely on the A1c to monitor your control. Test your blood sugar with a meter after meals frequently enough that you get a good idea of what your blood sugars are doing. If your A1c is much higher or lower than you expect, discuss this with your doctor. In this case, the fructosamine test may give you a more valid measurement of long term control.

Because there is a growing amount of evidence that it is blood sugars spikes after eating that damage your organs not only the glycation of proteins reflected in the A1c, it is dangerous to think a low A1c means you have nothing to worry about if your post-meal blood sugars are going into the damage zone.