Copyright 2017 Janet Ruhl

All rights reserved.

 

 

Published by Technion Books

 

This publication is sold with the understanding that the publisher and author are not engaged in rendering medical or other professional services. If medical advice or other expert assistance is required, the services of a competent professional person should be sought.

 

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Introduction

The chances are you’ve picked up this book because you or someone you care about have been diagnosed with Type 2 Diabetes and you’re filled with far more questions than your doctor can answer in the 15 or 20 minutes set aside for your latest appointment. If it’s been a while since you got that diagnosis, you may have started to wonder why so little of the advice you’ve received has made any difference. You’ve taken the pills your doctor prescribed, but your A1C remains stubbornly diabetic. You’ve tried eating the healthy diet described on the “Beat Diabetes!” flyer you were given and cut out fatty foods, but your fasting blood sugar keeps rising. You may even have joined a gym, but though you’ve lost a couple pounds, your toes are starting to hurt and your doctor just muttered something about early diabetic neuropathy.

Perhaps you’ve tried some alternative approaches and filled up your medicine cabinet with strangely named supplements that were supposed to lower your blood sugar but only lowered your bank balance. Maybe you’ve tried eating an alternative diet where you gave up everything you like to eat in favor of brown rice, raw fruit, and green leaves. When you burnt out on that you may have switched to an Atkins diet and eaten nothing but meat and cheese for a month, which lowered your blood sugar but made your breath stink so badly your spouse threatened to leave if you didn’t give it up.

Well, welcome to the club. This kind of journey is what most people go through when they get a diabetes diagnosis. But the frustration they experience during this initial burst of enthusiasm explains why so many people give up fighting their diabetes. They just take the pills they’re given, ignore their weight, and dread their doctor’s appointments.

This kind of denial can actually work pretty well for a while. Until it doesn’t. Feet start to go numb. The doctor mutters about your kidney function tests. The eye doctor tells you they need to see you every three months instead of just once a year.

I’ve been there and done quite a bit of all that myself, starting back when I was first diagnosed in 1998. But after going through years of the same kind of trial and error, burnout and denial, I got lucky and ran into some very smart people with diabetes on an online diabetes support newsgroup, alt.support.diabetes. The strategies they described, which made it possible for them to achieve impressive blood sugars, taught me that there are moderate, sustainable ways to control diabetic blood sugars that don’t require us to go to extremes. My subsequent research has confirmed that these approaches are safe and will prevent diabetic complications without requiring that we give up everything that tastes good, live at the gym, or obsess about our health 24/7.

I’ve been a professional writer since the mid-1980s. So as I started figuring this stuff out, I wrote about it and posted what I wrote online so other people wouldn’t have to waste as much time as I had on the error part of “trial and error.” Those postings eventually morphed into my website, Blood Sugar 101, which I started back in 2005. Since then, I’ve kept up with the research about diabetes. I’ve added new pages to the site whenever something important emerged and backed up the statements that appeared on the site with documentation that would let readers read the actual studies reported and draw their own conclusions.

The Blood Sugar 101 website grew so large that it became far too big for people to read all of it off of a screen. So in 2008 I turned the information stored on the site into a book, Blood Sugar 101: What They Don’t Tell You About Diabetes, which ended up spending two whole years at the very top of the Amazon Diabetes bestseller list. Readers loved it, recommended it to friends, and gave copies as gifts to relatives. These readers have turned Blood Sugar 101 into a diabetes classic. It is still available in a longer, fully revised second edition, published in 2016, which is still going strong.

Why This New Book About Diabetes?

Since Blood Sugar 101 came out, I’ve gotten hundreds of emails filled with questions from readers. Some, though by no means, all of those questions already were answered in Blood Sugar 101. But my correspondents seemed to have difficulty finding the answers to their questions in that book because of the way the information in it was presented.

This was understandable. Because I’m not a doctor or a trained diabetes educator, when I wrote that book I knew I couldn’t expect anyone to take my advice seriously unless I backed up every point I made with references to solid, mainstream medical research. To establish that I wasn’t just some off-the-wall crank, I had to go into great detail when describing the findings of the vast body of neglected mainstream medical research that supports the legitimacy of the powerful but unconventional strategy for combating diabetes that I laid out there. But that research got pretty technical at times, more technical than some of my readers were comfortable with.

So that made me think that a new book might be helpfulone that focused entirely on answering the kinds of questions my readers wrote me. This book wouldn’t need to cite the research that lay behind the answers I would give, because that documentation can already be found on the Blood Sugar 101 website or in the earlier book. Instead this new book would focus on troubleshooting Type 2 Diabetes. It would answer several hundred of the most pertinent questions readers had sent me over the years, dealing with them in the same way that I would have replied to them if I’d received those questions in my in-basket.

This is that book.

Some of the questions you’ll find here are very basic and may repeat information you’ve seen elsewhere. I answer those questions so that readers who are new to the subject of Type 2 Diabetes will get the grounding they need to be able to follow the more advanced topics covered further on. But many of the questions you’ll find here are those people with Type 2 Diabetes only know enough to ask years after a diagnosis, after they have tried various approaches and run into the problems that arise while trying to make them work. Those questions are rarely answered in other diabetes books currently on the market, because so few of those books are written by people who have lived with diabetes. These are questions that only a person with diabetes would think to ask—or be able to answer.

Though there is some overlap here with what you may have read in Blood Sugar 101, there’s also quite a bit I couldn’t fit into the older book. In particular, you will find much that is new in this book about how to make the most out of your relationship with your doctor. Since I wrote the first book back in 2008, that relationship has become even more difficult. Insurers now make it much tougher to get some of the prescriptions many of us need, and doctors rely a lot more on our A1C test results than they used to. These factors are making it much tougher to get the help we need to achieve the normal blood sugars that will keep us from developing the complications too many of our doctors assume are inevitable.

Over the last couple of years I’ve started hearing from quite a few readers who are being severely affected by these changes in the healthcare system. Though they’ve been very successful at lowering their blood sugars using the diet and drug regimens I described in Blood Sugar 101 and will lay out for you in this book, some report that their doctors or insurers have decided they no longer have diabetes and have taken away the drugs that let them keep their blood sugars so normal. This poses challenges new to those of us who have spent the past decades demonstrating that the terrible complications experienced by far too many people with Type 2 Diabetes are entirely avoidable. But they are solvable challenges, and there are a lot worse things you can hear in a doctor’s office than that your blood sugar has become too normal.

My hope is that the answers you’ll find in this book will ensure that that is the worst message you will ever get from your own doctor.

A Few Words of Caution

This book is written for people who have been diagnosed with Type 2 Diabetes. So when I write about “diabetes” in the following pages I mean Type 2 Diabetes unless I specifically mention a different type. While people with Type 1 might find some useful information in these pages, much of what is discussed here may not be relevant to them. Type 1 Diabetes is far more difficult to manage than Type 2, and controlling it requires a different set of strategies. So this is not an appropriate book to give or recommend to someone who has just been diagnosed with Type 1 Diabetes or its adult onset form, LADA.

The questions presented here are the kinds of questions I’ve been sent by the many readers who have contacted me over the years. My hope is that the answers to these questions give you a lot more insight into what it takes to master Type 2 Diabetes and that they also help you get the most out of the limited time your doctor can spend with you. But it is not my intention to provide specific answers to the kinds of questions that only your own doctor should answer.

I don’t have access to your medical records and can’t answer your specific questions about your health. I may point to what the drug’s label says about dosage or cite published research that highlights potential issues with a drug. But you should never rely entirely on any book for answers to questions like what specific dose of a drug you should be taking or whether a drug is safe for someone with some other medical condition you might have.

To get those answers you must consult with your personal doctor. I do occasionally point out situations where busy physicians may get dosages wrong or ignore important side effects or interactions with other drugs you are taking. If you aren’t sure about something your doctor has prescribed, consult with the registered pharmacist at the pharmacy that dispenses your medications.

Along the same lines, if you are having a scary symptom that you fear might mean you are having a dangerous hypo or a heart attack put down this book and don’t rely on Dr. Google. Phone your doctor’s office if you have a doctor. If you don’t, call an ambulance. I had an uncle who tried to save a few bucks by waiting until Monday to call his doctor about a nasty pain he was having in his chest, because he didn’t want to waste money going to the ER, since it might turn out to be nothing. It turned out to be something, and he didn’t live until Monday. So if in doubt, spend the money to get that expert opinion.

Note: Whenever specific blood sugar readings are mentioned in these pages, I give them first in the units used in the United States, mg/dl and then, in curly brackets, I give the equivalent value in the mmol/L units that are used in almost every other country around the world.

Chapter One: Help! I Have Type 2 Diabetes

I Just Got the News—What Should I Do First?

The first thing you may need to do is calm down, especially if your imagination is filling up with memories of all the awful things that happened to Aunt Maria, Grandpa Mike, or Mr. White at work, whose diabetes ruined their lives. Even the worst of today’s doctors does a better job helping patients avoid those terrible outcomes than was the case even 20 years ago.

But that said, you don’t want to calm down too much. Because the strong emotions you are feeling right now represent energy you can channel into doing what you have to do to ensure that diabetes never becomes more than a footnote to your life, not its theme.

It’s actually helpful to feel a little bit of panic at this stage. The people I really worry about are the people who don’t let their diabetes diagnoses upset them, who figure everything will be just fine if they take the pills their doctor gave them or drink more apple cider vinegar. A little terror is healthy if it gives you the energy to make some changes that are not easy, simple, or fun. It’s going to take work to put diabetes in its place—a lot of it. And you will have to keep on working at it for decades. There is no easy fix for diabetes. Anyone who tells you different usually has a bottle of expensive, magical moonbeams to sell you.

Which brings me to the next thing someone just diagnosed with diabetes needs to be aware of: when it comes to your health, the glorious world of Free Enterprise is a jungle where the wallets of people with diabetes the prey. Doctors who never got licensed to practice medicine, fraudulent supplement companies, and a whole zoo of “alternative practitioners” pay for their McMansions and country club memberships by selling miracle cures to frightened people diagnosed with chronic illnesses.

So before we begin, it’s helpful to repeat to yourself this highly protective mantra: There are no miracle cures.

Say it to yourself a few more times and then say it again. There are no miracle cures. You won’t cure your diabetes by eliminating all foods that start with the letter W. There is no magical plant from Southwestern Ubantuland, no healing food, no special oil, no electronic device, no yoga position, no prayer, and no cure so powerful that the medical establishment has kept it secret because if you knew about it, it would put them out of business.

There is only one real “secret” about diabetes that your doctor may not have informed you about, which is that it’s the carbs you eat that raise your blood sugar and that cutting those carbs will lower it. But that’s not much of a secret. Many thousands of people with diabetes already know it and use that powerful truth to keep themselves healthy.

But that’s pretty much it as far as simple secrets go. Because diabetes isn’t simple. It behaves differently from person to person. The food, drug, or exercise regimen that works for me may not work for you, and what works for you might not work for the lady down the street.

That’s why real diabetes solutions can never be described in 25 words or less. No matter how well any approach has worked for someone else, you’ll still have to test it out to see if it solves the riddle that is your own case of diabetes.

The point of this book is to give you the tools you need so you can test out any approach that appeals to you. It will also help you get past the many obstacles that arise when we follow even the most successful strategies for mastering our diabetes.

But these strategies are successful. So calm down. You’re going to be okay. You’re going to keep your toes and stay off dialysis. But don’t calm down too much. There’s work to do!

What Exactly Is “Blood Sugar?”

You were diagnosed with Type 2 Diabetes because your blood sugar was high. But what exactly does that mean? Well, for starters, the stuff your doctor calls “blood sugar” isn’t the same stuff you sprinkle into your coffee. It’s a simple sugar, glucose, which is unique because it’s the only kind of sugar your cells can burn for energy.

Glucose is even more essential for another reason. While most of your cells can burn fats if they run out of glucose, there are cells in your brain that can’t. If these glucose-burning brain cells are deprived of glucose for more than about six minutes, they die, and when they die, so do you.

How much glucose needs to be in your bloodstream to keep this from happening? Not much. The lowest blood sugar concentration at which you might still be conscious is 20 mg/dl {11.1}. That “mg/dl” means milligrams per deciliter, which is one tenth of a liter. So for you to stay alive, you need to have about two tenths of a gram of glucose dissolved in every liter of your blood. Since you have roughly five liters of blood circulating in your body, it takes only one gram of pure glucose to keep you going. That’s about a quarter of a teaspoon.

If you live in a country that uses the mmol/L unit to measure glucose, it’s helpful to know that one mole of glucose weighs about 180 grams, so a millimole weighs one thousandth of that, or .18 grams.

That 20 mg/dl {1.1} blood sugar concentration is the bare minimum you need to have at all times to stay alive, but it is dangerously low. That level is what doctors call “hypoglycemia,” or “a hypo” for short. The very lowest blood sugar concentration considered normal is 70 mg/dl {3.9}. When you have a typically normal blood sugar concentration of 85 mg/dl {4.7}, you have just slightly less than a teaspoon of glucose dissolved in your five liters of blood.

Though you may only have one teaspoon of glucose in your blood at any given moment, it takes a lot more than one teaspoon of glucose a day to keep you functioning. That’s because your cells are constantly using up the glucose in your blood and burning it to fuel their activities. So to keep your body going for a whole day you need a steady supply of glucose to replace what your cells have taken in.

That supply comes from two sources. The most important is the meals you eat and, more specifically, the starches and sugars in the foods that make up those meals. These sugars and starches are what we call “carbohydrates,” or “carbs” for short. When carbs are digested all the starches turns into pure glucose and so do some of the sugars. These digested carbs are the primary source of the glucose that circulates in your blood.

But what happens when you haven’t eaten for a while? That’s when you draw on your other source of glucose: your liver. The liver stores a backup supply of glucose. Some of it comes from excess carbs you’ve eaten, but if you aren’t eating carbs, your liver can also convert some of the protein you eat into glucose and store it too. During the long stretches that pass between meals and overnight, your liver releases a steady stream of that stored up glucose to keep your blood sugar from dropping below normal.

The amount of glucose in our blood fluctuates throughout the day, even in people whose blood sugars are completely normal. The graph below illustrates how a normal person’s blood sugar levels rise and fall throughout an entire day.





As you can see, this person’s blood sugars rise to a peak about an hour after a meal or snack. Then they sink back to the fasting level a few hours after the digestion of their most recent meal is complete. When they eat a large meal, like dinner in this illustration, it takes longer for blood sugar to drop back down to it’s fasting level. Snacks raise blood sugar, too. If they are eaten when a meal is still digesting they prolong the time that blood sugar stays above its fasting level. But in general, when the many, complex systems that regulate your blood sugar are all working smoothly, your blood sugar will stay pretty steady at your usual fasting blood sugar level until you eat a meal or snack.

Even with these continual fluctuations, blood sugar levels in fish, mammals, and healthy humans stay in a narrow range between 70 mg/dl and 140 mg/dl {3.9 and 7.8}.

Only birds and some amphibians can remain healthy when their blood sugars rise much higher than that. For example, some birds of prey may run blood sugars in the 300-400 mg/dl range {16.7 -22.2}. The record for highest blood sugar in any animal is held by hibernating wood frogs. They survive freezing solid in winter by letting their blood sugars rise as high as 100,000 mg/dl {5555.5}, which turns them, basically, into frog popsicles.

But we mammals can't withstand such high blood sugars. Blood sugars just five or six times higher than normal can kill us. Prolonged exposure to blood sugars that are only two to three times normal can destroy our hearts, kidneys, vision, nerves, and circulatory systems.

The table below displays some important blood sugar levels we’ll be concentrating on in the rest of the book.





What is Type 2 Diabetes?

Though Type 2 Diabetes is often discussed as if it was one disease like leprosy or measles, it isn't. Everyone diagnosed with leprosy has been infected with a specific bacterium. Everyone with measles has been infected with the same virus. But there is no one cause of Type 2 Diabetes. Breakdown that happens anywhere in the complex process of blood sugar regulation can raise your blood sugars to the levels that will produce a diabetes diagnosis. So technically speaking, diabetes isn’t a disease, it’s a symptom, and that symptom is high blood sugar.

Doctors divide people with blood sugars high enough to be labeled “Diabetes” into two main groups. The first they diagnose as having Type 1 Diabetes. These people have abnormally high blood sugars because something has destroyed the cells in their pancreases that secrete insulin. Without insulin their cells can’t burn glucose, so glucose from the meals they eat remains in their bloodstreams until its concentration rises so high it becomes life threatening.

How high is that? The Guinness World Record for highest blood sugar a person has survived is 2,656 mg/dl {147}. We aren’t quite in wood frog popsicle territory at that level, but it works out to very roughly 33 teaspoons of glucose in a body’s worth of blood—33 times normal. But that’s the world record. It doesn’t take blood sugars anywhere near that extreme to send a person with Type 1 Diabetes to the emergency room with a condition that can be fatal if not treated immediately. Most are diagnosed when their blood sugars are somewhere between 400 mg/dl {2.22} and 600 mg/dl {33.3}. That’s the level where most people with any kind of diabetes will start feeling very ill.

People with Type 1 Diabetes have completely lost the ability to secrete insulin. Usually this happens because an autoimmune attack has killed off the beta cells in their pancreas that secrete insulin. Occasionally people get diagnosed with Type 1 diabetes after surgery, a serious accident, or poisoning destroys their pancreas.

The distinguishing characteristic of Type 1 Diabetes is that anyone who has it must take supplemental insulin to stay alive. Before insulin was isolated from animal pancreases and made available to people with Type 1 Diabetes in 1922, the longest anyone had survived Type 1 Diabetes after a diagnosis was a year. And that was considered a medical miracle.

So why am I going on about Type 1 Diabetes in a book about Type 2? Because anyone whose diabetes doesn’t fit a Type 1 Diabetes diagnosis is automatically diagnosed as Type 2. It’s what they call a “garbage can diagnosis.” If you can survive without insulin your doctor will label you as having Type 2 Diabetes, but after you get that label they’re done. No further attempt will be made to understand what is causing your abnormally high blood sugars. This remains true even though over the past decades medical research has discovered dozens—maybe even hundreds—of different and sometimes unrelated causes for the blood sugar abnormalities lumped together under the label Type 2 Diabetes.

What they all have in common, besides the fact that you can usually survive them without needing to inject insulin, is that you can have Type 2 Diabetes and be running very high blood sugars for years without noticing it. None of the “Warning Signs of Diabetes” you will find posted on health websites shows up until you have had diabetic blood sugars for years.

You may be peeing a bit more than normal, or find yourself exhausted after eating. You may keep getting urinary tract or yeast infections, too. But there are plenty of other things that could explain these symptoms. What you won’t experience the kind of dramatic crises people with Type 1 Diabetes get because most people with Type 2 Diabetes are still making enough insulin to keep them alive, just not enough to lower their blood sugars anywhere close to normal.

So if people with Type 2 Diabetes can keep on with their lives even if their blood sugars are much higher than normal, why is Type 2 Diabetes a problem? The answer is simple: Over a long period of time those non-fatal, easy to miss Type 2 high blood sugars damage your blood vessels in ways that lead to heart disease and the nasty, painful, life-altering conditions known as the classic diabetic complications.

What Exactly Is Meant by the Term “Diabetic Complications?”

The word “complications” is a euphemism, a big fat five dollar word used to make some really ugly outcomes sound less scary. The classic diabetic complications include nerve pain, blindness, lower limb amputation, and kidney failure. But doctors avoid describing these conditions in such plain language. Instead they pretty them up with less frightening, technical sounding names. Nerve pain becomes “neuropathy.” (The Greek root “pathy” just means “disease.”) Blindness becomes “retinopathy.” Kidney failure becomes “nephropathy.”

But though doctors can make the names sound less scary, they can’t heal any of these conditions once they have become firmly established. So please, let the thought of complications frighten you enough that you do what it takes to ensure that you don’t get them. Despite what you might have heard, that isn’t all that hard to do, as you’ll learn in the next couple pages.

If you’re reading this at a time when you have already developed some early complications—you’re in good company. About half of all people diagnosed with Type 2 Diabetes already have some early complications on the day they’re first diagnosed. But that doesn’t mean you’re doomed. It just means that you’ll have to stop putting off doing something about the high blood sugars that are causing those complications. Lowering your blood sugar back to normal or near normal levels can heal up painful nerves and improve kidney function. It will prevent amputations and keep your retinas working the way they are supposed to.

If you’re impatient to know exactly how you will do this, you can skip ahead to the section in this book that tells you how. You’ll find it here.

What Causes Complications?

All the diabetic complications seem to begin after prolonged exposure to high blood sugars damages your blood vessels. These include the arteries that supply your heart and the much smaller blood vessels that supply your retinas, kidneys, and nerves.

High blood sugars make these blood vessels stiff and fragile. Over time they tend to rupture and bleed. When this happens, plaques in your coronary arteries give way and cause heart attacks, tiny capillaries in your retinas start leaking and are replaced by abnormal new ones, and the capillary systems in your kidneys stop filtering blood properly.

Nerve damage is the diabetic complication most people experience first. Like the other complications it is caused by damaged blood vessels, in this case the tiny capillaries that supply your nerves. When your nerves don’t get enough oxygen they start to die, starting from your toes up. This nerve damage hurts for a while. Then as it progresses your nerves die off and become numb. This may feel a bit better but dead nerves make you more prone to infections.

Amputations are among the most feared diabetic complications. Two factors work together to make them happen. The first is a side effect of your nerves having been destroyed by high blood sugars. That’s because your nerves do much more than let you know something hurts. They also notify the immune system when tissue is damaged or when you are under bacterial attack. Dead nerves no longer can do this, so invading microorganisms can feast on your flesh undisturbed, because your immune system is no longer getting the message that your defenses have been breached.

Even if your immune system does become aware that you are fighting off an invader, your sugar-clogged, damaged blood vessels make it hard for immune cells to reach the site of the infection. This is why people who have had very high diabetic blood sugars for decades end up suffering the incurable infections and gangrene that force doctors to amputate their lower limbs.

Several other conditions that often occur a while before someone is diagnosed with Type 2 Diabetes are also caused by damage to blood vessels. These include tendon problems like frozen shoulder and carpal tunnel syndrome, and, some doctors believe, vertebral disc disease. That’s because tendons and discs have a scanty blood supply at the best of times, so they are among the tissues that are the first to be affected when the smallest blood vessels begin to experience damage.

Does An Underlying Condition Cause Complications?

Many people have told me their doctors insist it isn’t just high blood sugars that cause diabetic complications and heart disease but that there is some underlying condition people with Type 2 Diabetes have that makes complications inevitable. I’ve heard the same story from my own doctors. If it really were true, it would be futile to try to lower our blood sugars to prevent complications. But it isn’t.

Many doctors seem to think that the underlying condition that makes complications inevitable is the insulin resistance they also believe is the main cause of Type 2 Diabetes. But people with Type 1 Diabetes get heart disease and all the rest of the classic diabetic complications despite having no insulin resistance at all.

Others point to obesity and the inflamed fat that often accompanies it as the underlying condition that causes diabetic complications. But again, that wouldn’t be a factor for people with Type 1 Diabetes who tend to be thin. Yet those thin, insulin sensitive Type 1s not only get heart disease and all the identical classic diabetes complications that obese people with Type 2 get—they get them at younger ages.

The only thing people with both types of diabetes have in common is that they all spend many hours each day with extremely high blood sugars. So it seems logical that exposure to high blood sugars is enough to explain why people with any form of diabetes get heart disease and all the classic diabetic complications.

What Blood Sugar Levels Cause Complications?

If it’s high blood sugars and only high blood sugars that cause complications, the obvious question to ask is, “How high?” I asked this question myself 12 years ago and then spent many months reading research published in medical journals to see if the data available there could point to a clear cut answer.

It turned out it did. Studies performed by researchers all over the world, who investigated the impact of specific blood sugar levels on individual cells, mice, rats, and large groups of humans all pointed to a very narrow range of blood sugars as being where trouble started. Not only that, but the toxic levels they identified turned out to be in the range doctors currently label “prediabetic.”

This explains why so many people with supposedly well-controlled diabetes get heart disease, nerve damage, and all the rest of the classic complications. This “prediabetic” blood sugar range is much lower than the level doctors tell their Type 2 Diabetes patients to aim for.

If you’re interested in the details, you can read about the studies that pinpointed the blood sugar levels that lead to complications on these two Blood Sugar 101 web pages: Research Connecting Blood Sugar Level with Organ Damage and Post-Meal Blood Sugars and High Normal A1cs Predict Heart Attack.

If you’re not into reading medical research papers here’s the short version: The very early changes in our blood vessels that eventually lead to heart disease start to happen when people’s blood sugars rise over 155 mg/dl {8.6} one hour after the start of a glucose tolerance test. (You can read more about this test here.)

Studies of large populations where blood sugars were estimated using the A1C test, which you can read more about here came up with a similar finding: People with or without diabetes whose A1Cs remain under 5.0% have the very lowest risk of having a heart attack.

This is true no matter what they weigh or what their cholesterol levels might be. That 5% A1C supposedly translates to an average blood sugar of 98 mg/dl. {5.4}. For each additional 1.0% rise in A1C in these large population studies the risk of a heart attack doubles though it still remains quite low until the A1C rises above 6.0%. That 6.0% A1C can be achieved by having blood sugars that average 126 mg/dl {7.0}. Since that is the average, people with a 6.0% A1C are almost certainly experiencing blood sugar fluctuations that are likely to rise well over the 155 mg/dl {8.6} level that other research points to as being the threshold over which arterial changes leading to early heart disease begin.

The level at which the rest of the diabetic complications start to become visible is only a little bit higher. They start showing up in people whose blood sugars remain over 140 mg/dl {7.8} two hours after the start of a glucose tolerance test.

This is a longer period of time than the one hour reading we just saw applies to heart disease. To have a blood sugar of 140 mg/dl two hours after consuming glucose, you would have to have had either a much higher blood sugar at one hour into the test or one modestly higher that took a long time to come down. Unfortunately, we don’t have evidence about what the peak was that people experienced while taking these glucose tolerance tests, only that two hours after they started, their blood sugar was still over 140 mg/dl {7.8}.

But what you should take away from this is that 140 mg/dl is the “magic number” when it comes to developing complications. It shows up as a critical threshold in studies of diabetic neuropathy (nerve pain), nephropathy (kidney disease), and retinopathy (eye damage). Blood sugars that stay over this level two hours after a glucose challenge—and probably after a meal—are doing damage. You should also keep in mind that doctors define that 140 mg/dl {7.8} blood sugar level as being only “prediabetic” and are not aware of how damaging they can be.

In the case of diabetic kidney disease, there is one more blood sugar factor that plays a part. Blood sugars that surge up and down steeply turn out to be worse for you than blood sugars, even high ones, that remain relatively flat. Something about large changes in blood sugar concentration seems to damage our kidneys.

There are a few other unpleasant conditions that don’t usually make it onto the list of diabetic complications that also become more frequent when people’s blood sugar are over 140 mg/dl {7.8} two hours after consuming glucose. The most notable are vertebral disc degeneration and tendon problems including frozen shoulder, carpal tunnel syndrome, and piriformis syndrome.

This research suggests very strongly that there is no mysterious underlying condition that causes diabetic complications. It’s the high blood sugars that do it and they start doing it at those prediabetic levels too many doctors ignore.

If the thought of getting your blood sugar down to anything remotely near normal fills you with dread because your readings now are so much higher, don’t despair. Lots of us have done it and have kept on doing it for a decade or longer. You can read many fascinating reports submitted by people who have made remarkable changes to their blood sugars on the Blood Sugar 101 web page The 5% Club: They Normalized Their Diabetic Blood Sugars and So Can You! There you will see that people with A1Cs approaching 17% have been able to get their blood sugar down to levels their doctors considered normal in only a few months. Not only that, many have kept on doing it year after year.

You can do it too!

Why Did My Relative Lose a Limb and Go on Dialysis?

It is hard for me to think about the extraordinarily poor care people with diabetes received a mere generation ago without being overcome with rage.

Doctors ordered their patients to eat high carbohydrate/low fat diets that made it impossible for them to control their blood sugars and left them ravenously hungry. When that diet didn’t work, they were put on either insulin or insulin-stimulating oral drugs. These drugs made them even hungrier while forcing them to eat carbs all day long in order to avoid having severe hypoglycemic attacks.

Hypos were a constant concern because people with Type 2 Diabetes had no idea how high their blood sugars were most of the time. Until the mid-1990s they were rarely given blood sugar meters. The first time I ever saw a meter was in 1985, during my second diabetic pregnancy—after I was wheeled into the delivery suite. Like everyone else with Type 2 back then, the only blood sugar tests I ever had were the ones taken when I visited the lab before a doctor’s visit. Even then, I had no idea how high my blood sugars were. All I was told was that they were diabetic. It didn’t occur to me to ask for more details.

Your older relatives not only couldn’t lower their diabetic blood sugars—since they rarely knew what they were—they were instructed not to. Because of the fear of hypos, conscientious doctors urged their patients to keep their blood sugars safely high. A1Cs of 9% or 10% were encouraged. It wasn’t until 1992 that a large study proved that lowering A1Cs to what at the time was considered a very low level—7.0%--made a huge difference in how many patients developed the most serious forms of all the diabetic complications.

So, this explains why, as recently as the 1990s, so many people with diabetes of both types lost limbs, went blind, and had their kidneys fail. Many more didn’t even live long enough to develop these classic diabetic complications, because their diabetic heart disease killed them first.

But diabetes care today is far better. You are no longer dependent on a semi-annual visit with your doctor for information about how your blood sugar is behaving. You can buy your own meter and strips at a drug store or order them online. Most insurance plans will cover testing supplies if your doctor orders them, and most doctors will prescribe them if you ask for them.

The low fat mania is over, too. Patients are no longer forced to eat fat-phobic diets so rich is carbohydrate that they push blood sugars up to levels no drug can control. Nor are we told to eat blocks of artificially colored, artery-clogging trans fat instead of butter. Excellent research has proven that diets that lower blood sugar by limiting how much carbohydrate we eat are safe and that dairy fats are not only safe but are a lot healthier than the highly processed vegetable oils that were considered healthy a generation ago. Even the American Diabetes Association (ADA) has grudgingly admitted that there is no reason people with diabetes can’t safely eat a low carb diet if they want to.

So the limitations that made it so easy for earlier generations to suffer so terribly from diabetes are largely gone. You are so much luckier than your elders. Make the most of it!


Your Diabetes Questions Answered: Practical Solutions That Work and Keep on Working is now available at these links:

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--Jenny Ruhl