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.