August 5, 2009

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?



butch said...

My mother just turned 83 last week.
She has diabetes since she was 55 and now she is controlling by dieting and glipizide.

When she was first diagnosed, her doctor put her on insulin. After 3 years, she got tired of the injections and got her doctor to try oral medications.

In her case it worked out. She is fanatic about writing every reading down and has years of history. Typically her morning fasting reading is always under 110 mg/dl.

luck to everybody.

trinkwasser said...

Some older folks are lucky, they were diagnosed at a time when a low carb diet was standard treatment and if no-one changed their diet in the meantime they have an excellent chance of remaining complication-free.

When I was diagnosed the Rule was that no medication would be available until A1c reached 8.

This has now been reduced, I think to 7, but then the following line has been added to most of the documents doctors are required to follow

 avoid pursuing highly intensive management to levels of less than 6.5 %.

In other words, we are going to kill you more slowly (sigh)

Sherlock said...

I really appreciate all the info you post. I was getting very discouraged that even with meds and cutting carbs, it's been hard to keep my levels below 140 at one-hour readings and under 120 at two-hour readings. My daily carb count is never over 30-45 for an entire day, and very few carbs between 4-8 pm (that's my bad time of day).

It's helpful to know that everyone is different and there are others like me who just can't tolerate many carbs.

I have given up so many foods that I love because of carbs. Now in the past month I've had to give up salads because of stomach issues. Not being able to eat salads has made things even more difficult.

But my A1C came down from 11.7 in January to 6.1 last month. I'm shooting for the 5% range!

I've found your information to be extremely valuable in keeping me motivated to eat right when the going gets tough!

Thank you!

Jenny said...


If you can't do it with diet, it is time to demand your doctor help you further.

I recommend metformin, possbily a trial of Byetta, and if none of those do it, insulin. Read the book Dr. Bernstein's Diabetes Solution to get an idea of how to use insulin with carb restriction. I find I can eat more carbs than he recommends and still get control, but I'm using insulins he hasn't used--Apidra and/or Novolog.

Sherlock said...

Jenny, I'm already on 1000mg of metformin twice a day and 1500mg of salsalate twice a day. Before the salsalate, the metformin was not working at all. Now together I'm doing much better.

I'm trying to follow Dr.B's plan. My doc didn't think the inability to tolerate carbs was unusual. I see her again in October so we'll see how the blood work turns out.

Brenda F. Bell said...

Other issues involved with untreated T2 involve delay in diagnosis (when -- if at all -- do doctors start routinely checking blood glucose levels, and/or do fasting blood work?), avoidance of standard health maintenance (consider the lack of affordability of annual checkups for minimum-wage workers, and twentysomethings paying back student loans, under traditional indemnity health insurance), and avoidance of treatment due to fear of costs. Check Evan Falchuk's blog post and the New York Times piece to which it responds.

pooklaroux said...

I am having trouble getting my doctors to help me address my rising blood sugar. My primary physician does not think it is "that bad" and pooh poohs my request for metformin. I just dropped my last endo because he was trying to give me statins against my express wishes, and he also seemed to think I was overreacting to "mildly" high numbers (let's see, now my fasting is running in the 130's. Last fall it was the 120's. I am getting stricter and stricter with food, and it is not helping.) And I have decent insurance! I am angry and frustrated, and really panicked because since I dropped my endo, my gp won't rx me metformin until I get a new endo. Metformin did seem to be helping, at least a little. I am beginning to think they delay treatment deliberately -- but I don't want to be blind or have limbs amputated. I do not find this situation amusing.

trinkwasser said...

Pooklaroux, I'm convinced you are right! In retrospect I had clear sympotms of disrupted BG going right back to childhood. A diabetic colleague diagnosed possible diabetes thirty years ago, yet doctors blew off my symptoms presumably as I had not YET crossed the Diagnostic Threshold. This story is not uncommon: an early diagnosis gives you that much more time to control the condition nefore it becomes uncontrollable.

Worse, I have read several stories of people who obviously suffered from LADA who were similarly blown off, and in one case had their insulin removed after it proved highly effective and replaced with metformin which did nothing (but is cheaper)

italiangm said...

Jenny, what do you think of the A1C recommendations at ?

Worthy of a separate post with your analysis, perhaps?

Steve, a member of the 4.9% club, diet only :)

Jenny said...


I thin the A1c is slightly better than the fasting glucose as an aid in diagnosing diabetes EXCEPT for one huge problem: people with anemia will get low A1cs no matter how high their blood sugars go. Family doctors don't seem to know this, so their diagnoses will be missed.

I think 6.5% will catch people going up over 200 mg/dl. I was at 6.2% at diagnosis in 1998 but in those days the top of the local lab normal was 5.7, so it might have actually been 6.5%.

I have heard from some people diagnosed recently via A1c whose blood sugars were borderline rather than extreme, so this does seem like an improvement overall.