Misunderstanding UKPDS - 7% is NOT a Good A1c.

The ADA board is full of people with A1c test results over 7% whose doctors tell them they are doing fine. They aren't. The doctors who tell them this are as irresponsible as if they told them not to worry about a "touch of cancer."

My guess is that uneducated doctors think an A1c near 7% is "fine" because they've only read the one line summary of the findings of the UKPDS. That "25 words or less" version is that people with Type 2 Diabetes who attained A1cs of 7% reduced the incidence of complications.

What this summary statement ignores, is that UKPDS also showed that, while the rate of complications in the population with A1cs of 7% was better than that in the population with A1cs of 9%, people with those 7% A1cs still developed microvascular complications at a very significant rate, and, even more importantly, they had not decreased their likelihood of dying from a heart attack or stroke.

Here's what the actual findings published in the British Medical Journal said:
Each 1% reduction in updated mean HbA1c was associated with reductions in risk of 21% for any end point related to diabetes . . . No threshold of risk was observed for any end point. [i.e. this stayed true as the A1cs continued to drop] . . .Any reduction in HbA1c is likely to reduce the risk of complications, with the lowest risk being in those with HbA1c values in the normal range (<6.0%)."

Does this sound to you like 7% is a good A1c? I don't think so.

Even more significant is that other studies show that to decrease the incidence of cardiovascular "incidents" i.e. heart attack and stroke, you need to lower A1c far below 7%.

The chart below, derived from the huge EPIC-Norfolk study makes it very clear that the risk of heart attack DEATH has already doubled at an A1c 6%. (from Medscape New Avenues for Complicated Patients with Type 2 Diabetes and Hypertension) The chart graphs the risk of death from various causes for various A1c levels. CHD: Coronary Heart Disease. CVD: Cardiovascular Disease (includes stroke).




Could any doctor who looked at this data complacently tell a patient that an A1c of 7.3% was fine?

Clearly, the only A1c that is truly "fine" is 5% or less. Many of us can't get there. I sure can't. But the 5%s are a whole lot better than the 6%s and with the 7 times higher risk of death at the 7% you'd have to be crazy to be complacent about an A1c that high.

If this is all making you nervous, don't despair. I know literally hundreds of people who have brought their A1cs into the 5% range, often starting from as high as 13%. The tools you use are cutting back on your carbohydrate intake until you can get under 120 mg/dl two hours after every meal and, if carb restriction isn't enough, well chosen meds, including the one drug that always works for people with diabetes: Insulin.

Normalizing blood sugar saves lives. It can be done. It must be done. And if your doctor won't help, find a new doctor. It isn't his eyes that will go blind, his feet that will get amputated, or his heart that will give out when you take his outdated and dangerous advice!

Diabetics Poorly Served by Ignorant Family Doctors

I get a lot of mail from people who read my "What They Don't Tell You About Diabetes" site. They have been to the doctor, but they have no idea what is going on with their health. Many of them, like me, are not overweight but have very high post-meal blood sugars, often into the mid 200 mg/dl range or higher. Some can't get any treatment at all, because their fasting bgs are near normal though after every meal they go way, way up.

Some are being put on drugs that aren't doing anything for their blood sugars and when that doesn't help, they're put on drugs that an educated doctor should know won't work for someone who has no response to the earlier drug. Some are being put on expensive new drugs that are not supposed to be given to people newly diagnosed and are not being given the cheap drugs with the long track record of safety that should be the first drug started. And others are on 20 year old 70/30 insulin regimens which are giving them continual hypos but have never heard of basal/bolus insulin treatments!

What is the common thread here? It's pretty obvious: it's family doctors who don't consider diabetes a condition that requires the services of a specialist. Family doctors who have only a very rudimentary knowledge of diabetes. Family doctors who learned about diabetes 30 years ago in school and whose only education in diabetes care since then has been provided by the pretty ex-cheerleader drug company reps. And who, if the drugs they prescribe don't work, just shrug and send the patient away without answers--though with a hefty bill.

What these doctors do know seems to be mostly what are the latest, hottest, new drugs that have the highest profit margin for the drug companies. Not what those drug's real side effects are. Not which patients it is appropriate to prescribe these drugs for. And certainly not what much cheaper drug is much more likely to lower their blood sugar better.

And when it comes to the people who are not 300 lb Type 2s with a family history of Type 2, these doctors are more than clueless. I ran into this myself, when the doctor at Kaiser Northeast told me my 240 mg/dl blood sugars were "nothing to worry about" since my fasting bg was under 126 mg/dl. But that was 9 years ago. And yet, every day, I'm hearing from so many people who have clear cut signs of genetic diabetes or of early LADA (a sl0w form of autoimmune that strikes adults) and whose family doctors have never heard of either condition and have never suggested that they see a specialist.

This is scary.

These aren't people who are imagining they have something serious going on. One lady developed gestational diabetes several weeks into the pregnancy (as did I) not at the 5th month as is usual and is diabetic now, though not obese. Her doctor doesn't seem to know about MODY. Another is being told she is normal based on a 5.0% A1c but she had a very recent Glucose Tolerance Test with a blood sugar well 200 mg/dl 3 hours after the start of the test. Her doctor doesn't seem to know that anemia can make an A1c test result worthless. Someone else was diagnosed with a fasting bg over 300 and is not on medications, just self-treating with herbs.

I hear from thin people who have kids diagnosed as Type 1, parents diagnosed as Type 2, and whose doctors have never mentioned genetic diabetes to them when they show up with diabetic blood sugar. With that kind of family history, their child may not be a Type 1 at all, they might have one of the genetic forms of diabetes that can be treated with pills. But these family doctors don't know about genetic diabetes so they just tell them they're type 2 themselves, prescribe pills, and that's that. And then there are the people with the A1cs over 8% whose doctors tell them to watch their diet and give them no other treatment.

There's something wrong when a person like me, who isn't a doctor and doesn't particularly want to be a doctor, seems to know more about appropriate diabetes treatment--as defined by current practice standards set by the ADA, AACE and other professional organizations--than the family doctors who people rely on for treatment.

But if you wonder why the incidence of diabetic complications just keeps getting worse and worse, and why the typical American patient's A1c is worse now than it was 10 years ago (according to the NHANES study), well, there's your answer.

Family doctors who don't keep up with the details of diabetes treatment as provided by education sources OTHER than cute little drug company sales chippies really hurt a lot of people with diabetes!

Healthy Whole Grains are like Healthy Filter Tip Cigarettes

Some poor victim, I mean patient, just posted on the ADA forums about a visit to the nutritionist where, having brought his A1c down from 12% to 5.8%, he was chided for not eating enough carbs!

In particular, he was told to eat 8 servings of grain each day.

I know, I know. By now I should be inured to this kind of stupidity, but reading something like this still does very bad things to my blood pressure.

The idea that people with diabetes should eat "healthy whole grains" is derived from a bunch of studies where people eating whole grains were compared to people eating junk food and found to have slightly better blood sugars. These studies are almost all funded by the companies that sell grain in one form or another. When people with diabetes eat those "healthy grains" their blood sugars may be slightly better than those eating marshmallow fluff, but their blood sugars are still much higher than is consistent with health.

This is very much like those studies that showed that filter tip cigarettes were healthier than unfiltered cigarettes. They look good until you notice that smoking any kind of cigarette causes cancer and heart disease at rates that are completely unacceptable.

But while researchers have compared the health of people who smoke with people who don't, you won't find large, well funded studies where people with diabetes who eat little or no grain of any kind are compared to people who ate these universally recommended eight servings of grain each day.

Nor will you find long term studies where they track the development of diabetic complications against grain intake over a decade. Why? Well, for starters, because such studies take a lot of money and almost all food-related research is funded by companies that sell the food being studied. It's in their interest to do small, sloppy studies, and to publicize the results of those studies only when they make their products look good. So yes, a study may "prove" that whole grain Cheerios are a "healthier" breakfast than sugar frosted flakes, but just about anything rich in protein is far better than either. Just don't wait for General Mills to fund that study.

I am old enough to remember when doctors all smoked and there were commercials on TV touting the brand that doctor's preferred. I probably won't live long enough to see the demise of the oxymoron "healthy grain".

Fortunately, you don't have to take any dietary advice on trust. Get out your meter and test those "healthy" grains. See what they do to your blood sugar. If you can stay at normal levels, eat them. If not, how about a nice cheese omelet. Afraid of the cholesterol? Relax. Eating cholesterol has no significant impact on your lipids a.k.a. Cholesterol. It is eating starch and sugar that raise the bad kinds of blood lipids.

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A visitor suggested I put in a link to back up my statement about the ADA's main contributors including a lot of junk food companies.

This was discussed and documented in an earlier post on this blog complete with link to the ADA's largest contributors and some information about what they sell:

ADA Nutritional Guidelines--Keeping Diabetics Diabetic

Lilly Knew Zyprexa Causes Severe Diabetes and Lied to Hide it!

In case you still are under the delusion that you can trust some drug companies to put patient health and safety ahead of profits, read this:

Lilly under Scrutiny on Capitol Hill

From the article:

===QUOTE====

According to Mr Gottstein in a February 13, 2007, interview with the Anchorage Daily News, Lilly's hidden document showed the rate at which Zyprexa causes diabetes, massive weight gain and other metabolic problems and that Lilly trained sales staff to mislead doctors about the drug's association with diabetes and illegally promoted Zyprexa for off-label use with children and the elderly. [Emphasis mine]

Families of deceased Zyprexa victims want criminal prosecutions. "Lilly executives should go to prison for knowingly being responsible for people's deaths, shattered families; ruined and grieving families," says Ellen Liversridge, whose 39-year-old son gained nearly 100 pounds while taking Zyprexa before he lapsed into a coma and died 4 days later of profound hyperglycemia in October 2002.

"Thanks to the FDA," she says, "there was no warning on the label of Zyprexa even though two other countries had made Lilly place warnings about diabetes, hyperglycemia, and death."

For its part, the secret documents show that Lilly was not the least bit concerned that patients like Ellen's son were developing diabetes. The company's one and only worry was that sales would fall when the news about Zyprexa's link to diabetes became made public. A July 7, 2003, "Diabetes Update" memo discussed the company's strategy to counter the negative impact on doctor's prescribing habits when news of the FDA's decision to add a black box warning about the diabetes risk to the label of Zyprexa became public.

"We must embrace the fact that many physicians are curtailing their use of Zyprexa (particularly in the moderately-ill patient and in the maintenance phase)," the Update said, "solely on the basis of personal fear (of being sued)."

To ward off the drop in Zyprexa prescriptions because doctors were afraid of being sued, the Update said Lilly should offer to indemnify doctors, in other words, cover any lawsuits filed against doctors as a result of prescribing Zyprexa. "Indemnification represents the most meaningful demonstration of confidence in Zyprexa--both with our customers and with our employees," the Update stated.

This plan was apparently successful with doctors after the risks of Prozac became public when documents disclosed in litigation that were also kept hidden under a court order were revealed in a subsequent lawsuit. "Our experience with Prozac," the Lilly memo states, "confirms the impact and goodwill of such an initiative."

===== END OF QUOTE======

What a great drug for Lilly! It costs more than $300 a month AND it grows the market for Lilly's expensive insulins by creating many thousands of new, permanent, diabetics. Gotta love it. And if a bunch of people have to die to increase profits, well, you can't make an omelet without breaking eggs.

Personally, I'd like to see the executives of these companies, the ones that knew that their drugs caused unnecessary deaths when prescribed off-label, and then put all their efforts into increasing off-label prescribing, hauled up on murder charges.

This is murder. The victims are as dead as if drug company goons had opened fire on them with a Glock. And there are thousands of these victims, far more than died at VTech. So why do the people who do this get away with only a wrist slap?

I'll finish with one last quote from the article linked above:
====QUOTE====
In the case of Zyprexa, Lilly has so far agreed to pay about $1.2 billion to settle cases out of court with roughly 28,000 victims. But here again, $1.2 billion for claims spanning a 10-year period amounts to petty cash for a drug with sales of $4.36 billion in 2006, and a 10% increase to $1.108 billion reported in the first quarter of 2007, over the first quarter of 2006.
===END OF QUOTE=====

KILLING PEOPLE SURE IS PROFITABLE!!!!!!

Digestive Tract Miseries with Regular Metformin

It's not worth it. Even though I was seeing a bit better blood sugar control at meal times while taking the regular metformin three times a day, the digestive effects were too much for me and though they got slightly better with time, they didn't get better enough.

So I'm back to using the ER (Extended Release) taking all 1500 mg at one time at 10:30 in the morning so that I get best coverage during Lunch and an early Dinner.

If you're having problems with diarrhea, nausea, etc, on regular Metformin, be sure to talk to your doctor about switching the the ER form. They cost the same amount. The Metformin ER is also available at Wal-Mart as a $4 prescription.

Byetta, Januvia and Insulin

Since I posted my blog entries on Januvia, and the associated page on my site, "What They Don't Tell You About Diabetes" I've received a lot of email from people who would prefer to take Januvia rather than Byetta and want to know my opinion about which is best.

My suspicion is that if you have found that you respond strongly to a relatively low dose of a sulfonylurea drug such as Amaryl or glipizide (the sulfonylurea drug found in Glucovance) you may respond strongly to Byetta and possibly Januvia, though everything I'm hearing suggests that far fewer people respond to Januvia than Byetta.

If you have no response to these drugs, it may indicate that you've gone past the point where stimulating your beta cells with any drug is going to produce insulin because you no longer have enough functioning beta cells left to respond to beta cell stimulation.

Januvia, if its safety concerns are addressed, may turn out to be the drug of choice for people with prediabetes or forms of diabetes in which fasting blood sugar is still fairly well controlled and loss of post-meal blood sugar control is the main problem.

However, what disturbs me is that I hear from far too many people who are walking around with dangerously high blood sugars who inquire about Januvia because they hope they can add another pill to their regimen in order to avoid going on insulin. This is a tragically misguided approach.

Insulin always works. For everyone. These newer drugs work only for some people and many times they do not lower blood sugars anywhere near a healthy level. I am disturbed by the number of doctors who, based on postings on the Byetta blog, are putting patients on Byetta who have blood sugars well over 250 mg/dl after meals. This is a level known to cause blindness, kidney failure, amputation and heart attack death. Most of the time, after taking Byetta for several months, these patients still do not have blood sugars that are anywhere near the complication-avoiding level of under 140 mg/dl at 2 hours which is recommended by the endocrinologists who make up the American Association of Clinical Endocrinologists.

In the old days, doctors defended not putting their patients on insulin saying the patients wouldn't take shots. Well, taking Byetta involves taking two shots a day and unlike insulin, Byetta shots can sting and often puff up into insect-like weals. Two shots a day of insulin, properly dosed could bring the blood sugar of these people down to a safe level. Byetta, which costs more than twice as much, does not.

So if you are already on a lot of oral medication and are still going over 250 mg/dl after meals, you probably should start out with insulin, get your blood sugars down to a safer, more manageable level to save whatever functioning beta cells you still have left, and then see if Byetta or Januvia can improve matters for you.

Neither of these drugs will help if your beta cells are dead, and the research we cite on our Organ Damage page makes it clear that prolonged exposure to blood sugars over 150 mg/dl kills beta cells dead. Only insulin, dosed properly, is 100% guaranteed to lower blood sugar.

Even scarier are the patients who report they are on insulin but are still getting extremely high blood sugars especially after meals. Clearly they are on a "one size fits all" insulin regimen that does not take into account their carbohydrate intake or their personal level of insulin resistance.

These regimens (many involving 70/30 insulin mixes) should be totally discredited by now, because they don't give good enough blood sugar control, but they are still used by many family doctors who were trained a decade ago or longer and are not well educated in how to use modern insulin. Some of these people,too, are on Basal insulin alone when they need meal-time insulin to control their dangerously high post-meal blood sugar spikes.

If you are on insulin and still getting very high blood sugars, you need to do two things. One is to read "Jennifer's Advice to Newbies" and try out Jennifer's advice for a month.

If that doesn't help, you must find a doctor who will work with you to find an insulin regimen that does control your blood sugar. When you've got your blood sugars under pretty good control, then you can start fooling around with new and experimental drugs. But the time to do that is when you aren't going into the over 200 mg/dl red zone after every meal!

Pet Food Poisons and Your Vitamins

In case you need more things to worry about, take a look at this article from the Washington Post:
It's Not Just Pet Food

Here's what stuck out to me, "Currently, most of the world's vitamins are manufactured in China. Unable to compete, the last U.S. plant making vitamin C closed a year ago. One of Europe's largest citric acid plants shut last winter, and only one vitamin C manufacturer operates in the West."

The rest of the article explains that there is no oversight of the food ingredients and vitamins coming into this country from China at the level where you'd detect poisons like lead, pesticides, and other toxic chemicals. We know that these are a huge issue with Chinese products destined for human consumption because there's a long history of Chinese people being poisoned by the products of the same manufacturers who are now selling their products to the rest of the world.

The Chinese have been pursuing what has turned out to be a very successful strategy whose goal--almost attained--has been to shut down competing factories all over the world by offering products at extremely low prices that factories elsewhere can't match. This is made possible by the Chinese government's manipulating the value of their country's currency so that the $.30 an hour they pay a worker has a buying power, in China many times that of $.30 in the U.S. or for that matter any other developed nation.

When there are no more factories left, of course, the Chinese manufacturers will be able to raise their prices, because it will take decades for other countries to rebuild their manufacturing infrastructures. And you don't even want to think about the military implications of the fact that the U.S. has lost most of its machine shops, steel mills, hard goods factories, etc. and that most "American" manufacturers are getting their "American" products manufactured in cheap Chinese factories because our laws (thanks to Republican friends of big business) allow a company to slap a "Made in America" label on imported item as long as one or two steps in the manufacturing process are done in the U.S..

But to get back to Diabetes. We all know what happened with the poisoned pet food. But that problem came to light because kidney failure in younger pets is not common, so when veterinarians started seeing a lot of kidney failure in younger pets, they raised the alarm.

The problem is that doctors expect to see kidney failure in people with diabetes of all ages. People with diabetes take a lot of vitamins and supplements--far more than the usual patient--but because of this expectation, if there was a toxic chemical in their pills--which is very likely and which, has, in fact, already occurred with some supplements made in China--doctors would be very slow to pick up on it.

It only took a handful of pet deaths to turn up toxic pet food. How many deaths of humans will it take until we notice the toxins caused by cheap Chinese-imported food and vitamin ingredients in human food? And how many of them are already occurring and being attributed to "diabetes" and "obesity"?

I've stopped taking vitamin supplements My original motivation was the large research study that showed that ingesting chemical antioxidants seemed to increase, rather than decrease mortality. With the latest news in view, one has to ask whether this may have had something to do with undetected toxins in the antioxidants used in the study, which probably came from China, given that as the article above states, they have driven all other countries out of the vitamin business.

I suggest you take a long hard look at the handfuls of supplements you're chugging, too, since they, too, probably come from China, and may have been processed with water laced with lead and industrial waste, to say nothing of doctored with ingredients not listed on the label, some of which are dangerous (but very cheap) prescription drugs.

I am also cutting way back on processed foods that might contain the questionable imported food additives. I already avoid hydrolyzed vegetable protein (MSG/soy product) because of its known unhealthy effect on appetite, but I'm adding gluten, guar gum, and a few other ingredients which were cited in the article above to my list of things to avoid. I don't eat a lot of processed food as it is, but it looks like I'm going to be eating a whole lot less.

Even so, it isn't possible to avoid everything dangerous. The irony with the pet food poisoning was that the supposedly "organic" pet foods turned out to be more toxic to pets than the cheap stuff I buy my kitty at Stop & Shop. That should be a warning to those of you who think that paying top dollar at Whole Foods protects you. A scan of the ingredients of most boxed and bottled "health food" products reveals that, besides the truckloads of sugar and starch that make them far from "healthy" for people with diabetes, they also contain lots of possibly imported ingredients like guar gum and gluten. As long as food manufacturers can buy an ingredient from China for one tenth of what it costs elsewhere, that isn't going to change.