June 15, 2009

A Hint of Intelligent Thought about Tight Control and CVD

Remember the much touted Veterans study where people with Type 2 diabetes who attempted what doctors call "tight control" (defined as an A1c of 6.5%) supposedly ended up with more heart attacks than those who didn't?

Well someone has finally put on what passes for a Thinking Cap in the medical community and looked more carefully at the findings. Their conclusions were presented at the 2009 ADA Scientific Sessions.

What they found was this: If you start shooting for tight control in the first fifteen years after a diabetes diagnosis you DO cut way down on heart attacks. By a whopping 40%.

But, if you start tight control only after the patient has had 15 years of poor control--fifteen years in which high blood sugars clog arteries, overgrow heart tissue, and destroy nerves and beta cells, tight control may make things worse, mostly, though mostly things worsen in people who suffer dramatic hypos.

You can read about this analysis here: ENDOCRINE TODAY: VADT: Early intensive control reduced risk for CV events.

This is a tiny step forward. If you'll remember, since the earlier study was published, along with the ACCORD (Avandia Can Corrupt Our Rotten Data) study, many family doctors have been warning patients with diabetes that it is dangerous to attempt to lower A1c to 6.5%. Some have even been urging patients to maintain the 155 mg/dl average blood sugar that will give them the 7.0% A1c these doctors consider "safe." Since we know that extended exposure to blood sugars over 140 mg/dl cause neuropathy, this is tragically flawed advice.

So if your doctor tells you that shooting for tight control is dangerous, remind him that this is only true if you have had A1cs well above 7% for 15 years. Otherwise, tight control will drop your risk of heart attack by 40%, which many times more than can be achieved by any other medical intervention or drug.

If your doctor continues to urge caution in lowering blood sugar and push statins on you as a proven way of preventing heart attack, find a new doctor, immediately. Because a doctor who doesn't understand the power of normalizing blood sugar in preserving health is as dangerous to you as a diet full of Krispy Kremes.

This finding reminds me a lot of what happened when the WHI results hit the headlines "proving" that estrogen supplementation worsened heart disease in older women. Later analysis of the data discovered that this was only true if you started the estrogen supplementation decades after the end of menopause, after the woman had already developed significant cardiovascular changes. Women who supplemented estrogen at the start of menopause did experience benefits and did not have more CVD.

Unfortunately, the public got the message that estrogen worsened heart disease, and the follow up, that it provided benefits if started near the onset of menopause, never made it out of the specialty conferences. I learned of it only after reading Hot Flashes, Hormones & Your Healtha book written by the doctor who was the lead investigator on the WHI. I am afraid the same thing may happen here with this new analysis of the Veteran's data. Doctors, and the public, got the message "Tight Control Causes Heart Attacks" they won't hear the rest: "Only in people who ignored their blood sugar for fifteen years or more."

Insight into Why Tight Control is Problematic after 15 Years of Uncontrolled Blood Sugar

A secondary finding that came out of the data analysis was this: "...patients who had severe hypoglycemia had an 88% increase in primary CV events and a threefold increase in CV death."

This is a smoking gun, people, but the researchers, who like most people researching diabetes seem to be woefully clueless about the impact of high blood sugars on the body, seem to have missed what this finding really means.

In a healthy person, there is an intact counterregulatory system which involves the autonomic nervous system. When you start to go hypo, it kicks in to force blood sugar back into the normal range. This system is so powerful that I have heard a person with Type 1 who as a teen attempted to kill himself with a huge insulin overdose report that it did not work--because that counterregulatory kicked in.

You can weaken your counterregulatory response over time if you experience mild hypos frequently enough that your blood sugar set point drops. This is a problem mostly for people with Type 1 diabetes who if they go low a lot may develop "hypo unawareness".

But the real reason that people who have had uncontrolled diabetes for many years develop a tendency towards hypos is actually something else: exposure to very high blood sugars causes neuropathy--nerve damage. And this damage doesn't just impact the sensory and motor nerves. It also impacts the autonomic nervous system. The system our body uses to regulate blood sugar which should kick in to prevent hypos.

So the extreme hypos that leave people with long histories of uncontrolled high blood sugars from Type 2 diabetes unconscious are a result of those years of high blood sugar, not an independent issue.

This is made crystal clear by this statement in the Endocrine Today report:
“It is important to note that this association between severe hypoglycemia and MI and mortality occurred in both the intensive and the standard groups, in contrast to prior perceptions that such hypoglycemia was just a problem with people on intensive control,” Stephen N. Davis, MD.
The hypos don't result from the use of insulin or other drugs in the effort to get tight control. The hypos stem from the destruction of the autonomic nervous system caused by years of glucotoxicity [poisoning by high blood sugar]. It is also very possible that the same autonomic nerve death that promotes hypos leads to dysregulation of the heart beat that increases the likelihood of heart attack.

So it is reasonable to conclude that people who maintain really tight control as soon as they are diagnosed--who maintain blood sugars low enough to avoid neuropathy--are going to preserve their autonomic systems intact, which will make it much less likely that they will suffer extreme hypos.

But Doctors Are Still Not Thinking Clearly

The one disturbing thing I see in the response to this latest study is this imbecilic comment:
“Unless other factors are present that would contraindicate intensive treatment, such as hypoglycemia, intensive control is appropriate in the first 15 years after diagnosis,” he added. However, it is unknown whether patients who have already been assigned to intensive treatment for many years can safely continue beyond the 20-year mark.
Using this kind of logic it's almost certain doctors will tell patients who have maintained perfectly normal blood sugars for 20 years that it is now "dangerous" for them to continue with tight control. Based solely on the experience of people who suffered 20 years of damagingly high blood sugars.

When will doctors bet taught that all the complications of diabetes are caused by high blood sugars and that in the absence of high blood sugars people will not develop diabetic complications? It is such a simple concept, but one that is so alien to so many doctors who still behave as if "Diabetes" were a discrete disease which ravages the body no matter what blood sugar level the patient maintains.

Huge Impact of HDL

One last very interesting finding of this study was that HDL was highly predictive of heart attack. As reported in Endocrine Today
HDL level strongly affected the primary outcome of CV events and total mortality. The benefit was as high as a reduction of 90%...For every 10 mg increase in HDL above baseline, patients had an 88% decrease in risk for CV events and mortality, a 50% decrease in risk for first primary CV event and a 55% decrease in risk for all-cause mortality.
This is huge folks. Statins do not increase HDL. Cutting carbohydrates dramatically will raise HDL for many of us.

Let's Talk about Truly Tight Control

The A1c of 6.5% which is what mainstream medicine defines as "extremely tight control" translates into an average blood sugar of 140 mg/dl. Since blood sugars that are over 140 mg/dl for more than an hour or two are linked to nerve damage, retinal damage and kidney damage, the 6.5% A1c, while an improvement on a 7.0% A1c, is not low enough to prevent the classic diabetic complications.

And because EPIC-Norfolk and other huge epidemiological studies find heart attack incidence rises dramatically as A1c rises in the 6% range, an A1c in the 5% range or lower would be much safer, if you can achieve it.

Not all of us can--I've discussed this elsewhere. The reasons may have to do with individual variants in the red blood cells measured in the A1c test.

So rather than obsessing about your A1c, which measures blood sugar only indirectly, by assessing its impact on something irrelevant to complications--proteins bound to hemoglobin molecules, why not cut to the chase? Measure your actual post-meal blood sugar. Highs after meals are the blood sugars that damage our organs.

Keep your post-meal blood sugars under 140 mg/dl (7.7 mmol/L) at all times as much as possible. Studies have shown that neuropathy does NOT correlate to either A1c or fasting blood sugar in people who are not diagnosed with diabetes, but it does correlate to their 2 hour glucose tolerance test results. When those are over 140 mg/dl the incidence of neuropathy starts to climb.

Prediabetics This is Your Wake Up Call

Obviously, the earlier you strive for extremely tight control, the happier your heart--and other organs will be. I run into so many people with pre-diabetes whose doctors seem to think that there is no point in doing anything until pre-diabetes turns into diabetes. This is like telling people it's a waste of time putting out small fires. Wait until the whole house is engulfed in flames before calling the fire department.

Diabetes is not a disease that suddenly appears when you get a diagnosis. The diagnostic criteria are arbitrary and recent research has proven that organ damage begins as soon as post-meal blood sugars rise above 140 mg/dl and stay there for any period of time. This may happen long before a person is diagnosed as prediabetic with a oral glucose tolerance test or fasting plasma glucose test.

So if you have prediabetes, or think you might be on your way towards it, based on having a family history of diabetes or a stubborn weight problem, start measuring your blood sugar after meals and take aggressive steps to lower your blood sugar to the safe level. You'll find the instructions for how to do that using a blood sugar meter (the Wal-Mart Relion works fine) here:

How To Get Your Blood Sugar Under Control.

I have heard from hundreds of people over the years who have followed these instructions and achieved A1cs in the 5% range, even though some started with A1cs well over 10%.

You can too. And now there is no reason at all for anyone diagnosed within the last 15 years to fear tight control.



Kate said...

nice post. Can you post a link to the Endocrine Today study you mentioned. I can't seem to find it. Or just email it to me. Thanks

Jenny said...

The link was there the "VADT" link, but it wasn't labeled clearly. I've fixed it.

Trinkwasser said...

Meanwhile, back at the ADA



anyone expect this to be translated as "If your A1c is below 6.5 you are NOT diabetic, and you are NOT prediabetic either as IFG/IGT no longer exists


I take back some of the nice thoughts I was starting to have about John Buse

Jenny said...


I haven't blogged about the A1c for Diagnosis decision because I am not sure what to think of it.

A1c is better than Fasting Plasma Glucose, which is all most people in the US have had for screening until now. So it probably will catch some people who were going undiagnosed.

OTOH, if someone is anemic or has a sickle cell gene (i.e. many Black people) the A1c may completely miss the diagnosis.

If we HAD to use an A1c I'd prefer it to be 6% rather than 6.5% with follow up via meter testing after meals. OGTT can produce hypos where meals produce diabetic highs in people who have strong phase 2 but no phase 1 insulin production.

The standards for A1c have changed in the past decade. I was at 6.2% at diagnosis in 1998 but the reference range for normal went up to 5.7% at that pre-standardized lab, so that might have been a 6.5% now. As it was, the doc said it was "normal" and told me to ignore it.

Anonymous said...

this may be the most interesting development of an otherwise slow meeting. First it will save money and time for all, which can't be discounted in our current healthcare crisis. Second, patients who show up with A1c > 6%(IGT IFG will still exist just not for diagnosis) are going to get treated one way or another by the majority of doctors albeit unofficially for now- either through counseling or metformin; at the very least patient awareness will be raised. Don't forget, it wasn't long ago that < 7% was our ADA target. Now we are getting statements that aggressive treatment in the first 15 years is the ADA expectation (slow progress is better than no progress). Finally, don't lose hope on Buse- he has a tough fight against "academia" and soon will have more ammunition to lower the target or push for pre diabetes treatment...

Anonymous said...

excellent post - I really learned a lot. I would like to read more about the hypos and its connection to the autonomic system - do you have any links?

Jenny said...

I don't have a specific link. Dr. Bernstein writes a lot about the impact of diabetes on the autonomic system in his book, Dr. Bernstein's Diabetes Solution. After I read that, I studied up some more about the autonomic system and its many functions. But there isn't one handy reference.

Harold said...

I think he heavy concentration of carbs in the US diet has skewed the A1c up to the level we see today which in many leads to diabetes. I think this is not normal and believe Bernstein is right when he says it should be in the mid 4s. When you read the forms it seems that many are trying desperately to find ways to eat carbs instead of just saying no.

Anne said...

Thanks for another great post. It is sad that most people will never hear this information that could save them years of complications.

Jenny said...

Here is a research link that connects autonomic neuropathy with heart disease in people with diabetes:

Asymptomatic Coronary Artery Disease Is Associated With Cardiac AutonomicNeuropathy and Diabetic Nephropathy in Type 2 Diabetic Patients Diabetes Care, Vol 22, Num 10, Oct 1999

Trinkwasser said...

"Finally, don't lose hope on Buse- he has a tough fight against "academia" and soon will have more ammunition to lower the target or push for pre diabetes treatment..."

I hope you're right there! I'll be more optimistic when he finally retires the "Eat More Grains!" page

Currently fuming as I was REFUSED an A1c and Full Lipid Panel as I am "not registered diabetic", I shall be having strong words with my GP but this I suspect is what will be occurring more often. My A1c has never been out of the fives due to Reactive Hypoglycemia, FBG is still normal and my GTT hit 195 but needed to be over 201 for diagnosis.

Nevertheless I have significant symptoms of both peripheral and autonomic neuropathy (both greatly improved through BG control)and had appalling lipids, now similarly largely normalised. Going purely on A1c I would be dead before I was diagnosed. Put the whole picture together and I have obviously been diabetic for many years.

All tests miss someone,relying on just the one saves money not lives. Similarly NOT pushing for tight control saves money not lives which is obviously why they are looking desperately for "proof" it is useless. Nice to see someone pissing on their firework.

High carb diets cause illogic in researchers. Discuss.

Anonymous said...

I just read some concerning news from Dr. Havas in the January issue of the archives of internal medicine. He is basically arguing (and surprising to much applause) that it is time to challenge "conventional wisdom" and that there is NO EVIDENCE that tight glycemic control in type 2 patients improves clinical outcomes. His evidence is the UGDP study and that the UKPDS was a flawed trial that only met 1 of its 25 endpoints and then continuing the diatribe into the ACCORD ADVANCE (which he acknowledged begrudgingly the renal effect) and VADT. It seems as though many physicians are jumping on board and claiming the ADA is being pushed to suggest flawed guidelines by drug companies. This article is even being touted by endocrinologists as viable. What is a patient to think? and more importantly do to dispell this type of rhetoric? Help

Jenny said...

What I think about the doctors fighting against tight control is exactly what you'd expect.

But I try to save my energy for productive action, rather than waste it getting furious at people who so cavalierly doom other people to suffering that is so tragically unnecessary.

I certainly don't hear from people who have maintained tight control and developed new classic diabetic complications that were not due to high blood sugars during the years they went undiagnosed.

But I do hear horror story after horror story of doctors who misdiagnose Type 1s as Type 2s, doctors who prescribe medicines entirely inappropriately. Even doctors who fight against letting patients get tests like C-peptide tests that would qualify them for pumps from their insurers.

Some seem to be doctors with personalities similar to the Craig's List Murder Med Student who decided they could kill people legally once they became doctors so why act rashly and risk arrest?

v/vmary said...

Hi Jenny,

I am aiming for tight control, but maybe i am driving myself crazy over trying to be too tight a la bernstein. if i am 100 to 110 for 2 to 3 hours after a meal, so i need to worry since i am below 140? yesterday at 5:30 i ate 2 scrambled eggs with 2 pieces of turkey bacon and a lot of sour cream. at 6 pm i took a leisurely walk of 30 minutes with my husband. at 6:30 i checked my blood sugar and it was 100. so trying to get tight control, i took a pleasant bike ride for 30 to 45 minutes. that dropped me down to 75, maybe too low, but i didn't feel shaky or hungry, so i had a glass of water and let it go. then before i went to sleep at 10:oo i tested my blood sugar and it was 100??? this morning it was 84.

i never count carbs. do i need to start? is staying at 100 to 110 for hours something i need to be concerned about?? thx!

Jenny said...

I have posted a lot of research connecting blood sugar levels and complications on this page: http://www.phlaunt.com/diabetes/14045678.php and this page: <a href="http://www.phlaunt.com/diabetes/15945839.php</a>.

If you can attain very low blood sugars without a struggle, great. But most people with diabetes can't. Keeping 1 hour blood sugars under 140 should be adequate.