May 5, 2010

ACCORD Redux: It's the High Blood Sugars, Stupid!

The ACCORD study has been used to justify the imbecilic idea that lowering blood sugar is dangerous to people with diabetes. ACCORD was a very large study in which one group of people with diabetes were given a strong cocktail of diabetes drugs with the aim of lowering their A1c below 6.0. Those drugs included sulfonylureas, Avandia and Actos, all drugs known to increase heart problems. The other group of study participants kept their A1cs in 7% or higher range recommended by the ADA. The result was that the group of people shooting for the lower A1cs had slightly more heart attacks than those maintaining mediocre control.

For perspective, it is worth noting that another larger study, ADVANCE, pursued the same strategy with different drugs and found NO excess deaths in the tight control group.

And in both studies, the group with tight control had less classic diabetes complications most notably neuropathy and kidney disease.

But because of that small number of excess deaths in the tight control arm of ACCORD, many family doctors are now telling patients that lowering blood sugar is dangerous. Fortunately, a new study of the ACCORD data puts this into perspective.

The study is:

Epidemiologic Relationships Between A1C and All-Cause Mortality During a Median 3.4-Year Follow-up of Glycemic Treatment in the ACCORD Trial. Matthew C. Riddle et al. Diabetes CareMay 2010 vol. 33 no. 5 983-990. doi: 10.2337/dc09-1278

This study found,
...a higher average on-treatment A1C was a stronger predictor of mortality than the A1C for the last interval of follow-up or the decrease of A1C in the first year. Higher average A1C was associated with greater risk of death. [emphasis mine]

These analyses implicate factors associated with persisting higher A1C levels, rather than low A1C per se, as likely contributors to the increased mortality risk associated with the intensive glycemic treatment strategy in ACCORD.

It doesn't get any simpler than that. It doesn't matter how much you lower A1c if you keep blood sugar higher than the level at which complications and heart attack ensue.

In addition, A1c is a poor indicator of post meal blood sugar, so it is possible to lower A1c without eliminating the blood sugar spikes over 160 mg/dl that we know are associated with a huge increase in cardiovascular risk. Details HERE.

If your doctor tries to discourage you from lowering your blood sugar, find a new doctor.

Careful, thoughtful analysis of the data from ACCORD and the Veterans Study which have been used to support the idea that lowering blood sugar is dangerous have really only proven the following:

1. Not lowering blood sugar enough to prevent organ damage kills people. You can read what peer reviewed research has learned about what blood sugar levels are associated with organ damage HERE. You can learn about what peer reviewed research has found about what blood sugar levels are associated with heart disease HERE.

2. Lowering blood sugar using dangerous oral drugs may slightly increase mortality. Avandia and Actos both raise the risk of heart failure in people who did not have it to start with. Some sulfonylurea drugs are associated with elevated heart disease risk. Details HERE and HERE.

3. Lowering blood sugar in elderly subjects only after they have gone through decades of terrible control and irretrievably damaged their hearts and other organs isn't very helpful but lowering blood sugar starting at diagnosis provides major long lasting health benefits. Details HERE.

4. Lowering blood sugar using a low carb diet is safe and effective and eliminates the threat of hypo and the potentially fatal side effects of oral drugs that only emerge after people take them for a decade or more. Details HERE. Even the ultra-conservative ADA, funded mostly by drug and junk food companies who lose profits when people with diabetes eat a low carb diet has had to admit this.

The problem with oral drugs is that they act on cell receptors that though they lower blood sugar also do OTHER things elsewhere in the body. Sulfonylureas stimulate receptors on the heart, not just the pancreas. TZDs convert bone stem cells into fat cells, leading to serious osteoporosis, long term. Januvia and Onglyza inhibit DPP-4 which is used elsewhere by the immune system to fight melanoma, ovarian cancer, prostate cancer and lung cancer.

Lowering blood sugar by eliminating as much carbohydrate as possible and if that doesn't provide normal blood sugars supplementing diet with the safest drugs: Insulin and metformin will provide major health benefits and keep you alive and healthy. And the sooner you start normalizing blood sugar after diagnosis, the more benefit you'll reap.


michael plunkett said...

If it wasn't so serious, I'd be on the floor laughing. Time after Time either the ADA or a proponet of their blindness supports the excat opposite of what a healhty Diabetic needs to do.

ShottleBop said...

Many thanks, Jenny for putting the effort into this blog that you do, and for the sane voice that you add to the discussion. Every newly-diagnosed diabetic should be given the link.

renegadediabetic said...

What passes for "science" in the medical establishment is apalling. Thanks for setting things straight. Seems that I can go blind, go on dialysis, etc. and the medical establishemnt says it's just the consequences of diabetes. But a heart attack, we we just can't have that. Keep your BG up and take your statins.

Alexa Fleckenstein M.D. said...

Thank you for some common sense!

Alexa Fleckenstein M.D., physician, author.

PinePienaarInfo said...

Wow! Jenny this is really powerful information. This is truly one of the best articles I have read lately and it puts things into perspective. I have added part of this into my blog.