He's Cured? Family Doctors' Diabetes Treatment Gets Even Worse

A medically naive friend called me up all excited yesterday. He'd just been to his family doctor--the one who diagnosed him with diabetes last year based on his fasting plasma glucose, and guess what. The doc told him he wasn't diabetic anymore!

Unfortunately for my friend, this was not because my friend had improved his blood sugar. Far from it. His fasting blood sugar had gone as high as 138 mg/dl (7.7 mmol/L) over the past few months.

The reason the doctor told him he wasn't diabetic was that his A1c was 6.4%. The doctor exlained that "the definition of diabetes has changed" and by the new definition, you need an A1c of 6.5% to have diabetes.

This is completely not true. The "definition" of diabetes is stated in a document created by the American Diabetes Association (ADA) an industry-funded charity that made itself the self-appointed authority on medical treatment of diabetes, despite the fact that it is controlled entirely by those who profit from treating diabetes, NOT by people who have it. The document is:

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 20: 1183–1197, 1997

This proclamation (whose troubling history you will find discussed in detail HERE) was amended after a huge outcry by the world diabetes community with this:

Follow-up Report on the Diagnosis of Diabetes Mellitus The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care Diabetes Care 26:3160-3167, 2003

It is still in effect. As you can see by reading it, Type 2 Diabetes is diagnosed with one of these three criteria:

1. Fasting plasma glucose greater than 125 mg/dl (7 mmol/L).

2. Two hour glucose tolerance test value greater than 199 mg/dl (11.1 mmol/L)

3. Repeated random readings--i.e. taken at any time--over 200 mg/dl (11.1 mmol/L)

What changed is that the ADA now recommends the use of the A1c--a test that can be performed in the doctor's office--to diagnose diabetes.

International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes.
The International Expert Committee: Diabetes Care July 2009 vol. 32 no. 7 1327-1334. doi: 10.2337/dc09-9033

This additional diagnostic criteria (which doesn't replace the earlier criteria) diagnoses diabetes when A1c is 6.5% or greater.

As is always the case, the ADA based this recommendation largely on data collectd in non-Western populations whose genetic forms of diabetes are different from those found in most Americans. As you can see HERE in the graphs the ADA experts supply, Americans (NHANES study) have a different pattern of developing retinopathy than do the Pima and Egyptians. But it is the Pima data the ADA used to set their diagnostic criteria for Americans. And they set the cutoffs at the level where Pima began to show retinal damage.

The ADA continues to define "diabetes" as if diabetes and retinopathy (retinal damage) were the same thing. In fact, retinopathy is a later diabetic complication. By the time people begin to show signs of retinopathy they will have had demonstrable nerve damage (neuropathy) for many years. This is because diabetic nerve damage is a much earlier complication, as is heart disease.

In any case, despite the ADA's arbitrary choice of the 6.5% A1c as the bottom of the diabetic range, the graphs the ADA supplies show that retinopathy shoots up as soon as A1c exceeds 5.9%.

And, as if that weren't enough of a concern, the in-office A1c tests doctors often use--because they can bill insurance far more than they pay for the test kits--is extremely inaccurate. They can be off by as much at .5% (i.e. giving a reading of either 6.0% or 7.0% when a lab result would be 6.5%.) You can read what independent studies have found out about the accuracy of doctor's office A1c tests HERE.

BETTER DIAGNOSTIC CRITERIA

We know from the research you can read about HERE that the onset of neuropathy does not bear any relationship to A1c. It correlates strongly, instead, to post glucose challenge readings over 140 mg/dl (7.7 mmol/L). This has been confirmed by several studies run by neurologists.

We know from research you can read about HERE that heart disease incidence rises significantly as one hour post-challenge blood sugars go over 155 mg/dl and that several studies have found the risk of heart disease rising in a straight line manner as soon as A1c moves up out of the middle 4% range and becomes significant at the A1c of 6.0%.

Kidney disease appears to be associated with A1c, too. It rises after A1c is greater than 6.0%. However, in the case of kidney disease, strong fluctuations in blood sugar seem to play a part. A blood sugar that surges high and then comes back down may give a modest A1c but it will still damage the kidneys. Details HERE.

The A1c might be a helpful screening tool for finding people with full fledged diabetes who are unaware that they have it. But based on the study you can read about in this earlier blog post, anyone with an A1c over 5.5% should be given a glucose tolerance test--the gold standard for diagnosing diabetes, or if that is cost prohibitive, they should use a meter to check their blood sugar after eating to see how high blood sugar is rising. Repeated blood sugar tests over 200 mg/dl (11.1 mmol/L) at any time are diagnostic of Type 2 diabetes.

Relying solely on the A1c is a mistake, as is made clear by this study:

A1C and Diabetes Diagnosis: The Rancho Bernardo Study. Caroline K. Kramer, et al. Diabetes Care Care January 2010 vol. 33 no. 1 101-103.doi: 10.2337/dc09-1366

which found:

The limited sensitivity of the A1C test may result in delayed diagnosis of type 2 diabetes, while the strict use of ADA criteria may fail to identify a high proportion of individuals with diabetes by A1C ≥6.5% or retinopathy.

Once you are diagnosed, the A1c is a very poor guide to how well you are faring.

Why? Because your number one goal after diagnosis is to avoid nerve damage, blindness, kidney damage, and heart disease. Even the ADA's own data shows that in European populations these all become significant as A1c hits 6.0% and when post-meal blood sugars are higher than 155 mg/dl (8.6 mmol/L).

The family doctor's reliance on the A1c greater than 6.5% to define diabetes means that you won't be told you ARE diabetic until you have sustained organ damage. If you let the doctor treat you only enough to keep your A1c between 6.5 and 7% (or higher) as most do, you are almost guaranteed to develop the classic diabetic complications over time.

Your doctor won't see the development of these complications as a sign his treatment is inadequate. Doctors expect people with diabetes to develop complications. That's because all their patients with diabetes who follow the ADA treatment guidelines do. It is also because most doctors don't realize complications are caused by high post meal blood sugars, not any independent disease process. So they do not tell patients that the single best thing they can do to preserve their health is to cut down dramatically on the carbohydrates they eat, which are what raises their blood sugar.

Those of us with diabetes who have not developed complications because we have pursued very tight control are often ignored by our doctors because they assume we don't really have diabetes. This has been my own experience. That my diabetes hasn't progressed over 12 years and that my A1cs have stayed in the 5% range is seen by my doctors as suggesting that I must not really have diabetes no matter what my readings are after a meal filled with high carbohydrate foods. They find it impossible to understand that my good outcome is because I've made hard choices with every meal I eat to ensure that I keep my blood sugars below the danger point as much as possible.

If you want to be a typical person with diabetes--one with painful feet, recurrent, resistant infections, deteriorating kidneys, and troubling growth of abnormal capillaries in your retina, by all means, use the ADA diagnostic criteria. Don't consider yourself diabetic until you have already developed early retinopathy. Follow the ADA's dietary recommendations and flood your blood stream with carbohydrates at every meal. Test only your fasting blood sugar, not the post meal blood sugars that correlated with complications. Keep your A1c at the 7% level where 75% of all Type 2 diabetics develop retinopathy. Enrich the drug companies, hospitals, surgeons, cardiologists, and family doctors who will earn more and more as you as you deteriorate and use more of their products and services.

Or get smart. Keep your A1c in the 5% range at all times--and lower if possible. Keep your post meal blood sugars under 140 mg/dl (7.7 mmol/L) at every meal, which you do by lowering your carbohydrate intake. Use only safe diabetes drugs in conjunction with limiting carbohydrate intake.

You can learn more about how to do that HERE.

Your doctor will tell you you don't have diabetes. And if we define "diabetes" as "on the verge of going blind, losing your kidneys, and having a heart attack" you won't.

If your doctor uses the fact you "don't have diabetes" based on the A1c test to deny you blood sugar test strips, and prescriptions for helpful drugs like metformin, find a new doctor who is better educated about diabetes, even if it means making a longer drive or paying a bit more.

It's your eyes, kidneys and heart that suffer when your doctor is too busy to understand what he reads in the pre-chewed newsletters, funded by drug companies, that he or she uses to "keep up with diabetes research." It's you who go blind, end up on dialysis, or die of a heart attack when he's wrong.