Why Thinner People with Diabetes May Have Worse Outcomes

A study published last week in the Journal of the American Medical Association (JAMA) came up with the conclusion that "Adults who were normal weight at the time of incident diabetes had higher mortality than adults who are overweight or obese."

The study can be found at:

http://jama.jamanetwork.com/article.aspx?articleid=1309174

If you have been doing a good job controlling your weight and read only the media reports about this study, you may have found it disturbing. If your doctor is one of those who only reads the "25 words or less" summary of medical findings, you may even hear that losing weight is dangerous for diabetics.

Hermes Florez, MD, PhD. Florez, the director of the division of epidemiology and population health sciences at the University of Miami's Miller School of Medicine, who wrote an editorial about this study  was quoted as saying, ""If you are normal weight, you may be at higher risk from diabetes, especially if your fitness status is not so good."

But even a cursory reading of the methodology used in this study should make it clear that the outcomes for people who were normal weight at their diabetes diagnoses has little to do with their weight or, for that matter, fitness.

The data used in this study came from pooling data from the "Atherosclerosis Risk in Communities study, 1990-2006; Cardiovascular Health Study, 1992-2008; Coronary Artery Risk Development in Young Adults, 1987-2011; Framingham Offspring Study, 1979-2007; and Multi-Ethnic Study of Atherosclerosis, 2002-2011."

As you will immediately notice, all but one of these studies go back 20 years or more, to the days before doctors understood that only by lowering blood sugar could people with diabetes avoid diabetic complications. So most of the people who participated in the studies whose data was used in this meta analysis were diagnosed in the bad old days, after which they were likely to have received extremely poor treatment.

How bad? Before the middle 1990s, patients diagnosed with Type 2 almost never were given home blood sugar meters. The only time their blood sugar was measured--fasting--was when they saw their doctor once every few months. Since the only drugs available to treat Type 2 Diabetes were the sulfonylureas which can cause dangerous hypos,  the only concern doctors had about these newly diagnosed people's blood sugar was that it not drop low enough to cause hypos. As a result, doctors encouraged patients to keep their blood sugars high and when they administered A1c tests doctors  saw no problem with patients maintaining A1cs in the 10% range or higher.

So what does this have to do with why their weight at diagnosis might have given normal weight people a higher likelihood of dying over the subsequent decades? Just this: Nowadays those of us who keep up with diabetes are aware that most normal weight adults diagnosed with Type 2 are very likely not to have classic  Type 2. Most have a slow-developing form of autoimmune diabetes called LADA that is very similar to Type 1.

This form of diabetes does not respond at all to the oral drugs that are somewhat effective for Type 2. But back in the days when patients had no way to test their blood sugar after eating and doctors considered A1cs as high as 13% "safe" these patients could go many years without being put on insulin. And even when they were put on insulin, because they didn't have meters, they injected only enough insulin to prevent the sky-high blood sugars that cause the fatal condition, diabetic ketoacidosis. Many patients on insulin still had blood sugars that rose into the 200s and even 300s.

So normal weight people with LADA would have ended up with blood sugars much higher than those of the overweight Type 2s who were more likely to respond to the sulfonylurea drugs and, later, metformin, most newly diagnosed people with diabetes received.

And because we now know that there is a straight line relationship (in large groups of people, at least) between A1c and the likelihood of heart disease, it doesn't take genius to suspect that the explanation for the extra cardiac deaths in the group of normal weight people with diabetes was the those much higher blood sugars they ran due both to misdiagnosis and to the way doctors ignored the damage caused by high blood sugars until the middle of the 1990s.

A second group of normal weight people diagnosed with diabetes as adults who are likely to end up with poor outcomes are people with milder versions of one of the many, unrelated, forms of genetic diabetes that are lumped together under the name MODY.

Many people diagnosed with MODY have family histories of relatives dying young of heart attacks while young and fit. This is probably because exposure to blood sugars that remain over 150 mg/dl for hours each day will over time cause the arteries to become diseased. People with these forms of MODY have had that kind of elevated blood sugar all their lives. But until very recently only those with the worst cases were diagnosed, and the rest, whose genes gave them "pre-diabetes" for much of their lives, lived with abnormal post-meal blood sugars for  many years, and only developed full fledged diabetes much later on in life, perhaps after becoming a bit more insulin resistant.

Because they were thin, doctors didn't consider a diabetes diagnosis when they had symptoms that should have pointed them that way.  (In my 20s, my doctors waved off my highly abnormal glucose tolerance test results as "nothing to worry about" precisely because I was normal weight.)

Some rare forms of genetic diabetes are caused by genes that damage not only blood sugar control but other organs, most notably the kidneys and the mitochondria. Mortality in families that inherit these unfortunate genes have nothing to do with diabetes but with the other organ damage that is due to these gene variants.

But for most people with either MODY or LADA it's pretty clear that if you keep your blood sugars in the normal range (under 140 mg/d--7.7 mmol/L) at all times you can, over time, reverse much of the damage that you have already suffered and avoid the premature heart attacks and kidney failure that carried off so many people diagnosed with diabetes in the past, when they were allowed to run very high blood sugars.

Comorbidities

There is also one other reason why thin people diagnosed with diabetes may have a higher risk of dying--one that wasn't addressed by this study's methodology. The journal article states that the data were adjusted for "demographic characteristics and blood pressure, lipid levels, waist circumference, and smoking status." However, what was left out was co-morbidities--i.e. the presence of other diseases.

One of the most important comorbidities to be considered is pancreatic cancer, since there is growing evidence that a very early symptom of pancreatic cancer may be the onset of diabetes. This is discussed in the Mayo Clinic web page HERE. A small but important subset of normal weight people who die prematurely with diabetes are people whose pancreases failed because they were infiltrated with cancerous cells.

In addition, many drugs used to treat cancers and life-threatening diseases are capable of causing diabetes, for example the steroids administered during chemotherapy or to treat COPD. Powerful steroids were also prescribed in the past to people with neuromuscular diseases like MS. Data sets like those glommed together in this study can't tell us whether a person was diagnosed with diabetes after a course of chemo or whether they died of cancer, COPD, or MS. So the presence of people in this data pool who were diagnosed with diabetes who also had one of these other life-shortening conditions could also explain a significant amount of the excess mortality this study uncovered.

Whatever the explanation, if you are a normal weight person diagnosed with diabetes, there's no need to panic. If you track your blood sugar after meals with a meter and keep it as close to the normal range as possible, you should do fine. The worst treatment doled out to people with diabetes nowadays is far better than what the people involved in these studies back in the late 70s, 80s and early 90s were given after their diagnoses, and for those of us who pursue normal blood sugars the future should be a lot brighter, no matter what our weight.

P.S. If your doctor tells you there's no point in losing weight because thin diabetics have even more heart attacks than fat ones, find a new doctor. I wouldn't have warned about this in the past, but over this past year I have been sent so many stories about doctors giving idiotic advice based on their having misunderstood a media report about a research study that I no longer assume doctors will even bother to read the full report before changing their practice recommendations.

Interesting Research Links posted on FaceBook since 6/6/2012

Here are links to and brief comments about the most important research findings I've posted about on the Blood Sugar 101 FaceBook page over the past six week.  I've put the most important in red.

"for women...moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303886/

(Thanks to Peter at the blog, Hyperlipid, for the citation.) This epidemiological study debunks the relationship of Total Cholesterol to cardiovascular death.

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Dr. Hattersley (the MODY expert)'s team identifies another gene associated with "Type 2" diabetes in normal weight people.
http://www.sciencedaily.com/releases/2012/06/120601103808.htm

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Low dose aspirin raises risk of severe stomach or brain bleeds especially in people with diabetes--cutting heart attacks at the expense of causing strokes and hospitalizations for gastric bleeding (which can be very serious.) A huge epidemiological study should make us rethink the recommendation of daily aspirin.

Research examines major bleeding risk with low-dose aspirin use in patients with and without diabetes
http://www.sciencedaily.com/releases/2012/06/120605172017.htm

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A new C-peptide lab test is ACCURATE (unlike the one you had) and can detect very small amounts of insulin production even in people
with longstanding Type 1. Worth reading in full.
http://blog.sstrumello.com/2012/06/new-c-peptide-assay-could-expand.html

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Study suggests physicians have no clue as to how to dose post-meal insulin for Type 2s. Shameful.

Patients requiring more than one dose of prandial insulin problematic for physicians
http://www.healio.com/endocrinology/news/online/%7B561B9C43-F901-4497-A57A-684BC9F530E6%7D/Patients-requiring-more-than-one-dose-of-prandial-insulin-problematic-for-physicians

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Duh. Basal insulin alone is is far more effective than expensive, dangerous oral drugs that may promote cancer. Why does the doctor who comments on this sound so surprised?

http://www.healio.com/endocrinology/news/online/%7B98FB0916-9882-4F51-A2E8-7D9CD2B01C72%7D/Insulin-glargine-bested-sitagliptin-for-HbA1c-reduction-in-insulin-nave-type-2-diabetes

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Fish oil (omega-3) fails to affect heart disease or deaths in 12K subject, 6+ year study.

N–3 Fatty Acids and Cardiovascular Outcomes in Patients with Dysglycemia — NEJM
http://www.nejm.org/doi/full/10.1056/NEJMoa1203859

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Whoops, fish oil fails to demonstrate brain-protecting effect in random controlled trials. The way doctors continue to insist it must be good for you reminds me of the response to the low fat diet research that showed the diet did not help prevent heart disease.
http://www.bbc.co.uk/news/health-18410324
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Byetta produced A1cs in the 5% range for 1/3 of those who took it in this trial, duplicating what we've seen elsewhere, along with weight loss. Don't let your doctor put you on Victoza instead of Byetta. Byetta is a safer, better tested and more effective drug in the same price range.

Exenatide twice daily versus glimepiride for prevention of glycaemic deterioration in patients with diabetes.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60479-6/abstract

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A lower carb, med-adjusted diabetes diet causes modest but maintainable weight loss and blood sugar improvement over 4 years.
http://www.sciencedaily.com/releases/2012/06/120612192756.htm

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You need to eat fat with your salad to properly digest the micro nutrients.

Study: No-fat, low-fat dressings don't get most nutrients out of salads
http://www.sciencedaily.com/releases/2012/06/120619230234.htm

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1 in 500 obese patients in the open [WLS] surgery group died during or shortly after the procedure, compared to one in 1,000 in the laparoscopic group. But doctors who recommend WLS tell patients to avoid tight blood sugar control as it is "dangerous." Please show me where 1 in 1,000 patients die from tight control!

http://www.reuters.com/article/2012/06/20/us-lessinvasive-weightloss-surgery-idUSBRE85J19920120620
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A frightening look at what heartless people whose only interest is their own profits recommend. Raise the A1c for older people to 8% and you eliminate lots of Medicare recipients. And don't forget to enrich surgeons while killing 1 out of 200 people who have WLS. Criminal!

Wall Street Journal: New Strategies for Treating Diabetes
http://online.wsj.com/article_email/SB10001424052702303292204577517041076204350-lMyQjAxMTAyMDAwOTEwNDkyWj.html?mod=wsj_valetleft_email

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A good example of the isomer problem I discuss in Diet 101. The lab-created isomer kills people and is the one found in supplements, rather than the expensive natural one.
http://www.sciencedaily.com/releases/2012/07/120712131721.htm

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Dramatic illustration of difference between visceral (unhealthy) and subcutaneous (cosmetically unappealing) fat. CT scans.

How fat is fat? : The Lancet
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61925-9/fulltext

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Phthalates are plasticizers and in most soft bottles and much packaging. Research suggests they are a cause of diabetes.

Diabetes could be linked to phthalates, chemical in common household products, study suggests

http://www.boston.com/dailydose/2012/07/13/diabetes-could-linked-phthalates-chemical-common-household-products-study-suggests/2maQ1UQWxz1pZoKqAOmBFO/story.html

Jimmy Moore interviews Jenny Ruhl yet again in this new podcast

That sweet-talking Jimmy Moore worked his usual interview magic in yet another podcast which just went live on his site. If you have comments or questions feel free to post them in the comment section of this post.

http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-582-jenny-ruhl-gets-real-sharing-the-truth-about-low-carb-diets/14390

Interesting Research (FaceBook Links posted since 5/14)

"for women...moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial."

(Thanks to Peter at the blog, Hyperlipid, for the citation.) This huge, long epidemiological study debunks the relationship of Total Cholesterol to cardiovascular death.

THIS IS IMPORTANT. Read the study and look at the charts. (Note: Total cholesterol of 5 mmol/L is 193 mg/dl,  7 mmol is 271 mg/dl.)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303886/

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A study confirms that low carb diets are safe for the kidneys. (Not the first, but a fairly large one.)

http://www.foxnews.com/health/2012/06/01/are-low-carb-diets-safe-for-kidneys/
Good news. The CVD death rate among people with diabetes declined by 40% (95% CI 23–54) and all-cause mortality declined by 23% over the past decade.

Trends in Death Rates Among U.S. Adults With and Without Diabetes Between 1997 and 2006
http://care.diabetesjournals.org/content/35/6/1252.full


OBJECTIVE To determine whether all-cause and cardiovascular disease (CVD) death rates declined
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Carotid intima-media thickness does not reliably correlate with heart disease risk--though drugs are being sold based on studies that assume it does.
Carotid intima-media thickness progression to predict cardiovascular events in the general population

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60441-3/abstract

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In case you don't have enough reasons already not to take Actos. Like brittle bones, macular edema (leading to blindness) and causing heart failure.

http://www.medicalnewstoday.com/articles/246065.php

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This may give hope for some people with advanced diabetic neuropathy whose wounds don't heal. The underlying cause is damage to the nerves supplying extremities which are essential for triggering the release of the various immune system com...See More
Discovery Promises Unique Medicine for Treatment of Chronic and Diabetic Wounds
http://www.sciencedaily.com/releases/2012/05/120528100242.htm

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This backs up what some smaller studies I've seen have found. Exercise works well for some, for others it has no effect, and for some it makes health worse.

Can Exercise Be Bad for You?
For Some Exercise May Increase Heart Risk
http://well.blogs.nytimes.com/2012/05/30/can-exercise-be-bad-for-you/

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People diagnosed with Type 2 under 30 may have MODY. "Only 47% of MODY case subjects identified met current guidelines for diagnostic sequencing." Especially likely if diagnosed under 30 or under 45 without "metabolic syndrome."
Systematic Assessment of Etiology in Adults With a Clinical Diagnosis of Young-Onset Type 2 Diabetes


http://care.diabetesjournals.org/content/35/6/1206.abstract

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Diet causes growth of neurons in the hypothalamus leading to weight gain. I wonder if SSRIs also cause this overgrowth in they hypothalamus. They do in the hippocampus. (Note this is a mouse study, but it has very interesting implications.)
Weight struggles? Blame new neurons in your hypothalamus

http://www.sciencedaily.com/releases/2012/05/120521115331.htm

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Not really diabetes news but absolutely amazing. Use of sound gives people born blind ability to read eye charts.
Training the blind to 'see' using new device to 'listen' to visual informatoin


http://www.sciencedaily.com/releases/2012/05/120516093156.htm

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Fake industry-supported lobbying groups ensure your right to be exposed to endocrine disrupters linked with diabetes and worse.
Are You Safe on That Sofa?

http://www.nytimes.com/2012/05/20/opinion/sunday/kristof-are-you-safe-on-that-sofa.html

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Yet another study showing that cutting carbs lowers blood sugar that will be ignored by the ADA.
Swedes Lob Dynamite Into a Controversy: High-Fat Diet Improves Blood Sugars - Diabetes Health


http://www.diabeteshealth.com/read/2012/05/20/7533/swedes-lob-dynamite-into-a-controversy-high-fat-diet-improves-blood-sugars/

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It's only 7 years since I posted the documentation supporting the idea that prediabetic blood sugars cause neuropathy. Now the Lancet acts like this is news.

http://www.healio.com/endocrinology/news/online/%7BFEC3820C-6604-4589-B8A7-600E7938AFD9%7D/Prediabetes-other-metabolic-syndromes-could-be-linked-to-neuropathy

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"Sulfonamides, macrolides and other antibiotic traces have been found [in baby food], as well as anthelmintics (anti-worm) and fungicides." Another subtle factor damaging our genes?


New method detects traces of veterinary drugs in baby food

http://www.sciencedaily.com/releases/2012/05/120518132416.htm

The Problem with FaceBook

As an experiment, I set up a Blood Sugar 101 FaceBook page last year to see if I could spread more awareness of blood-sugar related issues.

The page attracted a lot of interest and currently has over 1,100 "likes." But FaceBook had to do something to justify the billions it winkled out of investors, and what it has done is pernicious.  After urging content providers to generate likes--even suggesting that we advertise with FaceBook to raise the number of people who like our page (I didn't), FaceBook has now stopped showing page updates to most people who have liked our pages.

I had noticed this when I reviewed the feeble stats that FaceBook provides for pages. Then I read online that only 20% of people who had liked a page were seeing the updates. A poll I posted as an update on the Blood Sugar 101 FaceBook page a few weeks ago confirmed this. Only 20% of the people who had liked the post responded to a question about whether they could see the feed.

Now when I post on the Blood Sugar 101 FaceBook page, FaceBook is hitting me with something new--a chance to PAY for the ability to have my status updates seen by the people who have already liked the page. (Details here.) For a mere $5-10 bucks per update I can ensure that people who subscribed to my page under the impression that it meant they would see the updates can see those updates.

If this had been explained explicitly when I created the page, that would be one thing. But this was not at all the way that FaceBook worked a year ago when I started the page. For example,  FaceBook has also disabled the ability of page owners to contact those who have liked their pages--a feature that was  intact when I created my page and was part of what attracted me to doing it.

I don't spam people, but now and then it would be nice to be able to send out messages about particularly important events. Not so coincidentally, FaceBook took away my ability to contact page likers just at the time they started charging for the ability to have those same subscribers see feeds.

This is making me seriously reconsider whether I should post on FaceBook at all. FaceBook is using the fact that people like my page to gather information they sell to marketers who then target those people. Since my page discusses diabetes and diet, people who like the page will get shown ads for the kind of crap exploiters love to push on people with diabetes.

Since Blogger has never played these kinds of games with me I'm liking the blog more and more and am thinking I'll move my posting activity back to the blog. But because many of the people who do still see my feeds have asked me to keep the FaceBook page going, for now I am going to keep the Blood Sugar 101 FaceBook page alive.

However, if you are on FaceBook and interested in seeing the feeds there, don't assume FaceBook will show them to you. To see the updates, you'll have to bookmark the page and remember to visit it from time to time to see the updates.

If you are active on FaceBook, it would be a good idea to also warn your friends that FaceBook is probably not showing them the feeds from pages they want to follow and that they are charging page creators for the "privilege" of having their feeds seen. Though you may find that many of those who have liked your page are no longer seeing your feeds either.