Why Type 2s Get Complications: Delayed Treatement until A1c Reaches 9%

The great tragedy of Type 2 diabetes it's terrible complications are all avoidable, but they occur because family doctors ignore their patients' Type 2 Diabetes until their blood sugars have been damagingly high for many years.

This was documented in a recent study published in Diabetes Care.

Sustained Hyperglycemia Among Patients With Diabetes: What matters when action is needed? Jennifer E. Lafata et al. Diabetes Care, Diabetes Care August 2009 vol. 32 no. 8 1447-1452 doi: 10.2337/dc08-2028.

The abstract is difficult to understand, but you can read a clearer discussion of the results in Diabetes in Control here:

DiC: Income Level Affects Treatment of Hyperglycemia.

As explained in Diabetes in Control, the study found that "41% of people with sustained hyperglycemia failed to get appropriate care within six months; 25% failed to get care within a year; and 11% failed to get appropriate care for as much as two years." "Sustained hyperglycemia" was defined as "two A1cs >8% and no recent medication intensification."

To put this in perspective, it helps to know that an A1c over 8% represents an average blood glucose of 183 mg/dl (10 mmol/L) . But the study found that many doctors did not begin to address these dangerously elevated blood sugars until the A1c was over 9% which represents an average blood glucose of 212 mg/dl (11.8 mmol/L).

Another study also published in the same issue of Diabetes Care puts this information into stark perspective. It tracked

...adults aged ≥20 years who participated in Third National Health and Nutrition Examination Survey (1988–1994) and had complete information, including baseline diabetes status by self-report and measured GHb (n = 19,025) and follow-up through the end of 2000 for mortality.

and found:

Among adults with diagnosed diabetes, having GHb ≥8% compared with GHb <6% was associated with higher all-cause mortality (RH 1.68, 95% CI 1.03–2.74) and heart disease mortality (2.48, 1.09–5.64)

That means that you are two and a half times more likely to die with an 8% A1c than with one below 6%. And these statistics don't even begin to get into what happens to your eye, toes, and kidneys while you're waiting for that heart attack.

All the traditional diabetic complications begin when post-meal blood sugar stays over 140 mg/dl for a few hours. All: Neuropathy, Retinopathy, and kidney failure. So a study that documents that some patients have to wait as long as five years for doctors do get more aggressive about lowering their blood sugars should answer the question, "Do all people with diabetes have to deteriorate?" with this answer: "No. Only those with doctors who ignore their plight."

Sadly even when doctors do "treat" those people with 8% A1cs, they usually do it by prescribing oral drugs which, as you've seen in the many posts I've written about new drugs can usually lower A1c about .5% and almost never can bring A1c down to the 5% range that we know eliminates complications.

That's because the only way most of us can lower our blood sugars to safe levels is to cut back dramatically on our carbohydrate intake. For many of us, just cutting way down on carbs is all it will take. Some of us will need to add carefully chosen oral drugs to a regimen of carb restriction. Some of us, self included, will need to use insulin or insulin and oral drugs along with carb restriction. But with some combination of these tools ALL of us can achieve safe blood sugars and avoid complications.

But sadly most doctors have no understanding of the power of carb restriction. They are deluged with drug company promotional materials which suggest that oral drugs alone are enough for most people with Type 2 Diabetes.

This is simply not true. There is no drug that will allow a person with diabetes to eat 300 grams of carbohydrate a day no matter how "low glycemic" and see an A1c low enough to protect health. Most of us can't eat even 150 grams. I can get away with eating up to 100 grams a day using insulin at meal times but not every day. An intake of 80 grams a day is a much better level for me.

I hope the information in this study should help you understand why so many people with Type 2 diabetes do develop complications and see their health deteriorate: because they spend years with extremely high blood sugars that are continually at levels we know destroy organs.

Knowing this should help put to rest your fears that you are doomed to deteriorate because you have been given a Type 2 Diabetes diagnosis. People whose doctors let them continue with A1cs just under 9% will deteriorate, guaranteed. For that matter, so will many people whose A1cs are at the 7% level the ADA recommends. This is the lowest A1c most people can achieve when taking a full complement of oral drugs or even insulin when they continued to eat diet high in carbohydrate. The 7.0% A1c corresponds to an average blood glucose of 155 mg/dl (8.6 mmol/L) which is still well over the 140 mg/dl (7.7 mmol/L) ceiling of the safe zone.

But if you keep your average glucose at least under 125 mg/dl (7 mmol/L)and ideally closer to 100 mg/dl (5.6 mmol/L) you should end up with the 5% A1c that normal people have and the normal health that they experience.

If you are having trouble getting your A1c down and you aren't getting help from your doctor, try the technique described here:

How to Get Your Blood Sugar Under Control

It's simple and it works.

But what it will take to get doctors to realize that their neglect is causing an epidemic of completely unnecessary death, amputation, blindness and kidney failure is harder to understand.

Type 1s are getting a lot fewer complications these past couple years, thanks to their access to pumps and continuous glucose monitoring. Most Type 1s are shooting for truly healthy blood sugar goals now, and it shows.

But, if anything, many Type 2s are getting poorer treatment now than they were in the 1990s. This is because there are many more oral drugs on the market than there were then. Some NHANES data suggests doctors are less likely to prescribe insulin now to people with extremely high blood sugars, preferring to add oral drug after oral drug, even though the oral drugs are far less effective than insulin in lowering very high blood sugars. As a result the number of people with Type 2 whose A1cs are in the 7-8% range that are the best the oral drugs can achieve climbs--along with the profits of the drug companies whose marketing is so effective in convincing doctors to put off insulin therapy.

Tragic, isn't it?