Glycemic Control For Fun And Profit

According to the American Diabetes Association, 25.8 million children and adults in the United States—8.3% of the population—have diabetes (90-95% are type 2). This includes 18.8 million who are diagnosed and 7 million who are “undiagnosed.” And, if that weren’t bad enough, the ADA estimates that there are also 79 million so-called “prediabetics” in this country. Much more statistical information—and some elucidation of the dubious methodology behind it is available here.

Why dubious? At best, these widely touted statistics are pedal to the metal extrapolations from National Health and Nutrition Examination Survey data, which examines “a nationally representative sample of about 5,000 persons each year.” Given the mind-boggling complexity of human pathophysiology, does anyone actually believe that such a small sample could produce meaningful results?

Evidently, the brain trust behind NHANES, as it is affectionately known, believes it, and offers as proof its “biggest success story.” That would be getting people scared about high cholesterol and its alleged connection to coronary heart disease. Great work, guys! Your biggest success has been disproved a thousand times over, and led to the currently recommended high carb/low fat diet, which causes diabetes, and in turn increases the risk of heart disease. Or, maybe, since 80% of type 2’s are overweight or obese, it is this corpulent state, of which type 2 is merely an adaptation, that is increasing the risk.

Sadly, such loopy number games are not limited to big picture statistics. In fact, the quintessential number game in diabetes is glycemic control—the maintenance of designated blood glucose levels. Newly diagnosed type 2’s are given a litany of complications that can occur, absent glycemic control. And herein lies the rest of our story.

A curious aspect of internal medicine is its obsession with target blood titer values. To be sure, such figures can be important guidelines, but should they be primary goals in themselves? A few years ago, an IM doc of my acquaintance appeared very depressed. One of his patients had died the previous evening, and he was at a loss: “Her numbers were all OK, I just don’t understand it.” In deference to his mental state, I refrained from replying, “Did you think death was optional?”

Given the millions afflicted with diabetes, you’d think there would be plenty of data establishing the importance and validity of glycemic control. Not exactly. A frequently cited study from 1995 examined various morbidities in type 2’s on insulin therapy. The cohort was relatively young and not obese. This work compared the results of a “conventional” insulin therapy group (1-2 injections per day) with a “multiple” injection group (3 or more per day). The multiple group had better outcomes over the six year period.

The authors acknowledged that their findings were contrary to many earlier studies whereby intensive glycemic control in sicker patients was detrimental. Indeed, the famous 2008 ACCORD study (Action to Control Cardiovascular Risk in Diabetes) was stopped when too many of the intensive control group (using oral meds and insulin) died. In the 2008 ADVANCE study, although issues with participants going hypoglycemic were observed, the results here were at least partially positive for the intensive group. Notably, the primary financial support for ADVANCE came from Servier, a major supplier of oral hypoglycemics, and no stranger to drug scandals.

The UKPDS 34 study of 1998 involved overweight type 2’s and did compare intensive drug therapy with diet alone, with respect to microvascular endpoints. The drug group fared better, but the diet was high carb/low fat. The NICE-SUGAR study (2009) showed that ICU patients under intensive glycemic control fared worse, contradicting the Leuven Surgical Trial (2001) although the groups studied were not exactly comparable. There are also studies showing the value of tight glycemic control on type 1’s, usually involving sick patients.

As to type 2’s, the trend of the research is that there is no benefit to tight glycemic control. Bear in mind, though, that virtually all the literature involves patients who already have vascular conditions, and are complicated by polypharmacy issues (patients on several concurrent drugs).

In other words, if you seek a longitudinal study of normal weight otherwise healthy type 2’s, who maintain tight glycemic control versus those who do not, you’d be out of luck. And really, why should anyone run that sort of study? Sales of insulin, oral hypoglycemics, and testing supplies are skyrocketing without such data.

13 responses to “Glycemic Control For Fun And Profit

  1. The other stat that is not mentioned is that once diagnosed with diabetes you will have died from complications of diabetes regardless of how you died. For example my grandmother died at the age of 94 but the death certificate shows cause of death from complications of diabetes. She was a diabetic but it seems to never have occurred to any one that a 94 year old individual just died from normal old age. She lived on her own until that last 6 months or so of her life.

  2. The money quote here:

    “A curious aspect of internal medicine is its obsession with target blood titer values. To be sure, such figures can be important guidelines, but should they be primary goals in themselves?”

    Absolutely spot on, only I would extend this to all “health” indicators (especially BMI). An obsession with target values based on little or no evidence of harm has become the be-all and end-all of our medical system. It has allowed medical professionals to separate an actual condition from a measurable factors and promoted treating the numbers instead of the condition. Type II diabetes is the ultimate example as it is defined by blood glucose levels – with no actual health condition bar some statistical correlation.

  3. @Ken–

    Absolutely correct. Of course, cause of death has been estimated to be wrong 30-50% of the time. I apologize for not also mentioning this aspect, but you will find that once you venture into the world of orthodox allopathic medicine, there are contradictions at every turn.

    Indeed, my mother-in-law died last year at 94 and was given at least two insulin injections per day. Who cares about glycemic control in an old lady in assisted living? Anyone who can bill for the related services, I guess.

    And, there are MANY cases of death related to folks going hypo because of intensive glycemic control. Here is a personal favorite…

    I knew a guy in his early 70s who was an active mens’ tailor. One day, his wife called 911 for some issue, and the poor guy was stupid enough to be wearing a MedicAlert bracelet for his type 2 diabetes.

    Well…Whatever distress he was in caused his glucose to go hyper (no surprise there), and the paramedics gave him insulin. He went hypo and died. I guess they didn’t get the memo that no one has ever died from going hyper, but folks die all the time from going hypo. Yep, his cause of death was “Complications of diabetes.”.

    Collateral damage…

  4. “There are also studies showing the value of tight glycemic control on type 1′s, usually involving sick patients.”

    If you are Type 1 you are by definition a very sick patient. Death without external insulin would come in a very short time …

    • @JeffC–

      The point here is that studies on type 1’s have been purposely conflated with type 2 studies to further confuse the public. And, the ones I refer to were type 1’s in hospital.

      Many type 1’s would be insulted to be thought of as “very sick.”

  5. With the financial pressures put on doctors and hospitals by the government to meet “patient care” goals it sems all medicine is getting to be a numbers game (BMI, cholosterol, glucose, etc.). Actual patient care and attention is almost missing except in ICU/Trauma units. Most primary care doctors I have seem and heard about are concerned first with numbers and then with completing the EMR. Sad!

  6. Now that we have meters that send data over wifi we could get blood data on scads of people. I’m not sure how useful it would be but the button sorters could get lots to sort.

  7. Glycemic control is easy if you lay off the carbs. No Type 2 should ever need to be on meds, and everyone would be healthier on a high fat/low carb diet. The carb heavy government food pyramid and the doctors who parrot it are the problem.

    Fat and protein are required macronutrients, carbs are not. See the Inuit for an extreme example.

    • My husband was put on insulin, and that was enough to force him into a drastic change of diet. He had been cutting back on carbs already, but he went cold-turkey: no carbs, no fruit, no vegetables. Just meat and fat, and some seasoning. Took him about four months total, two months cutting back on the insulin bit by bit, and then another two months for the glypizides. With some really nasty hypoglycemic episodes a few times. He is now a diabetic in remission. He has been able to add back a few carbs without his blood sugar reacting, and has become quite a chef, inventing various sausage recipes, and making some gourmet chocolates using the diabetic sugar. It can be done, but it takes a lot of will-power, determination, and home-cooking.

  8. @Janice–

    Thanks. For overweight type 2’s, insulin therapy is almost always a bad idea. Why? Insulin will cause the patients to gain weight, causing more insulin resistance, requiring higher doses of insulin—vicious circle.

    And,oh yeah–as you say—the patient can go hypo.

    Best of luck to you and your husband!

    • Michael, your comment reminded me . . . my husband, when he was finally off all the diabetes meds, lost about 75 pounds. It was almost like the meds were keeping him chubby. The only down side is that the cats used to like sleeping on top of his belly while he was sitting, and now that he doesn’t have a big belly, they just sort of roll off of him. They are really confused.

  9. @Janice–
    No “almost” about it. Insulin forces glucose into the cell, thus promoting weight gain.

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