April 6, 2010

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.


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.



RLL said...

I had repeated difficulties with doctors not supporting my goals. A plum spur into a finger initiated a cellulitis episode. Nurses at the hospital told me that the Community Clinic (one of the good things George W expanded) docs would. They have, I actually go to a PA now, he is also good at athletic injuries. Community Clinics are suppose to attract some people with better insurance, I have found them much better than other clinics.

michael plunkett said...

Wow, Jenny, another hit 'em where it hurts post. Your combination of knowledge and common sense outshines anything the ADA and their minions can give their patients or Diabetic community that sees them as the authority and final word. And that is a crying shame.

Anonymous said...

Yes, Exactly. I have been denied treatment precisely because I immediately started testing and changing my diet -- and the better I do the harder it is to convince my doctors I really do need that metformin. This is asinine, and I don't know how deep this will have to go before it starts moving in the right direction. I am still looking for a better doctor.

water said...

oh, forgot to ask - how's the book coming along?

Anne said...

I have had abnormal OGTT's for 40 yrs but never abnormal enough for my doctors to call it diabetes. The last one about 10 years ago and my 2 hour test was 202. That was still too low for my doctors to think blood glucose played a part in my CAD and neuropathy.

About a year ago I bought a glucometer and started eliminating foods that spiked my blood glucose. My PCP agreed that I have diabetes and I have been able to get the strips through my insurance plan.

At first I was able to get my fasting down into the 80's and after meals lower than 120. These numbers are beginning to creep up and now I am wondering if I need to get on Metformin. I will find out what my doctor thinks in a couple of weeks.

Jenny said...


The first book is just about ready for printing, but won't release until September 28. I'll post the cover next month as it's embargoed until then. I'm working full time on the second book which is due in two months. Lots more to do but it's getting there. . .

Susanne said...

A very diabetic (and extremely overweight) woman today told me her fasting blood sugars were over 500 before she was diagnosed as diabetic.

When my FBS tested at 138, my Dr. told me it was stress and not to worry about it.

We are all here with Jenny because we (to some degree) have taken our diabetes management into our own hands. I just shudder to think how many clueless diabetics and their doctors are out there. How much damage is happening....

Lori Miller said...

I talked to a lady yesterday and the subject turned to health. She had fibromyalgia, she was quite overweight, suffered from depression at times, and was beginning to have peripheral neuropathy. I asked if she had diabetes, and she said that her after-meal BG was 190 at times, but that wasn't a problem because her A1C was fine. Sigh.

PRIVATE said...

I am pre-diabetic and recently started Metformin. I was in ketosis for a very long time mainly because I had extreme insulin resistance, but I'm slowly getting out of ketosis and probably could not have done so without Metformin. I want to exercise more and cannot without a few more carbs in my meals. Anyway, I'm having problems with what seems like peripheral neuropathy, I get cold and hot feet, and pain when I walk sometimes, and my toes feel a little numb on the tips....the thing is, my carb intake is still considered low to normal, I'm just now trying to up my carbs a little because the Bernstein type diet I simply cannot follow, I cannot get through my workouts without some carbs. I don't understand how I can be dealing with these symptoms though. For example, I had cooked spinach and fish and I started to yawm and have some pain on my left side, and I checked my one hour and it was 5.2 mmol/L and the 1.5 hour was 4.9 mmol/L and the 2 hour went to 4.0 mmol. These numbers look fine to me, and I don't even have high numbers in the morning, this morning my fasting was 4.0 mmol/L. Could my body just be having a hard time getting the blood sugar down and my pancreas is somehow failing ? Also, after a couple months on Metformin I am losing ALOT of my hair and it can't be anything else because that's all I'm takiing right now. I'm seeing my doctor soon and was wondering if you have any advice or questions I could ask him as to what exactly is going on. Thanks !!

Jenny said...

The blood sugars you report sound completely normal. If they were high before you started the diet the feelings you are reporting may be from nerves that are healing--if, in fact, you had neuropathy due to blood sugar.

In that case, be patient it takes a while for the nerves to heal. It is also possible something else could be going on with your feet, not related to blood sugar. There are other forms of neuropathy. Ask your doctor about this. If you have ever had back disc problems, they can also cause numb toes completely independent of blood sugar.

PRIVATE said...

Thank you for responding so quickly. You have an amazing blog/website, do you have a book as well and where can I purchase it ? To respond to your response, I didn't have any burning feet or the other issues I have now before starting Metformin. But from what I'm being told, pre-diabetes can carry the same symptoms as frank diabetes. I also had blurry vision and all the other symptoms of diabetes prior to starting Metformin, and I believe that I am at the border between pre-diabetes and type 2 at this point. But I'm reading that B12 deficiency can occur with Metformin and it can also lower your TSH as well....my TSH prior to starting Met hovered around 3.90 to 5, so maybe this could be the reason for the excessive hair loss. I also have reactive hypoglycemia quite often, (another pre-diabetic sign apparently) and if I have to stop Metformin then I'm hoping that there are other meds, maybe I'll ask my doctor about Byetta instead. I hope someone comes up with a real cure some day because diabetes just plain sucks.

Jenny said...

@Private: My book is "Blood Sugar 101" you can buy it at any online bookstore.

You would have to take Metformin for several years for it to deplete B12 significantly.

Hair loss sometimes happens when people lose a bunch of weight on diets of all sorts, but in that case it will come back as the hairs haven't died.

If you have thyroid issues that could also explain your symptoms, but I have not heard of Metformin worsening thyroid.

PRIVATE said...

Okay great, thanks.
I just read somewhere that even high doses can cause the B12 deficiency and I do know that my B12 prior to starting Metformin was already low to begin with as well. Well, I'll just ask my doctor to test my B12 and see where it's at.
As far as the TSH info, I found some articles on Pubmed about this, but I'll ask my doctor when I see him. By the way, do you also do speaking engagements or appear on TV as well ? If not, then you should. I also think everyone who is diabetic should be made aware of this website. As I continue to search through your website I am finding a wealth of useful information. Cheers !

Jenny said...

@Private, I pretty much write. No one has invited me to any public events, but the blog, site and book reach thousands of people, so that works for me.