Tag Archive for: diabetes

Guidelines for Type 2 Diabetes: EBM in Practice

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The American College of Physicians (ACP) has established guideline statements for the management of HbA1c in non-pregnant adults using medication. They considered the research behind guidelines set by four other major physician organizations for treating type 2 diabetes. After reviewing that data, they have proposed four guidelines for use when treating patients. These are non binding guidelines; the choice is always left to the physician and the patient. But I think they get back to what evidence-based medicine should have always been about: use the best science and research and work with the patient to see what they want to do. Let’s take a look.

ACP Guideline Statements

These are the statements:

Guidance Statement 1
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

Guidance Statement 2
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

Guidance Statement 3
Clinicians should consider de-intensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

Guidance Statement 4
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

EBM and Guideline Statements

I think the Guideline Statements reflect what EBM was always supposed to be about: consider the patient and what they want. I have spoken to many adults with type 2 diabetes who become frustrated with their inability to reach the HbA1c goals their physician has set. If they can’t reach it, more medication seems to be the only solution, and that’s not what they want.

I think these guidelines bring the patient or their caregiver into the equation. What price does the patient have to pay with their body? How much will it affect their life positively or negatively? Are there real improvements in quality of life if the HbA1c is 6.5% versus 7.0%? What is the cost of emotional stress?

The new guideline statements are a great addition to a physician’s repertoire: treat the patient as an individual. The patient comes before statistics and hazard ratios.

The Bottom Line

While not all organizations are going to adopt these guidelines, they’re important. There has been significant pushback from other organizations, all suggesting that there are new medications that may prevent some of the negative effects of prior treatment. “New medications”—they’ve learned nothing.

The one opportunity I see is that there’s hope for all of us who want to work at getting control of our lifestyle and reduce the dependence on medications as recommended by statement three. You say you don’t want to take medication? Excellent! Here is your chance to prove it.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.

 

A New Approach to HbA1c

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Type 2 diabetes is a significant problem in North America and it’s spreading throughout the entire world. The treatment standard has always focused on controlling blood sugar, especially HbA1c. Normal is less than 5.7%. For most individuals, reducing the HbA1c to under 6.5% has been the goal for pharmacologic treatment.

HbA1c is a protein found on red blood cells that indicates blood glucose levels over the past 90 days. It develops when hemoglobin, a protein within red blood cells that carries oxygen throughout your body, bonds with glucose in the blood. Think of it as the sugar you ate over the last three months getting stuck to your red blood cells; the higher your HbA1c, the worse your control of your blood sugar has been. For a prediabetic, that means your days of diabetes meds and finger pricks is getting closer. For a diabetic, that opens the door to many of the worst consequences of diabetes, such as heart and kidney disease, blindness, and nerve damage.

Recently, the American College of Physicians published new guidance statements for the use of medications for controlling HbA1c. A committee of physicians examined the data behind the current standards of treatment for four of the major physician organizations including the American Diabetes Association. In the simplest terms, they wanted to know what benefits or hazards occur when treating adults with type 2 diabetes with medications. Should the goal be to get the HbA1c as low as possible with drugs? Or should the individual be part of the treatment equation?

This is an important issue and the topic for this week. I’m going to review evidence-based medicine on Thursday. You can get the entire story by listening to the Straight Talk on Health on evidence-based medicine, normally available only to Members and Insiders; I cover the entire concept of how EBM began and what it was intended to be. For those of you who haven’t chosen a membership yet, get more info here.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.

 

The Bottom Line on “What the Health”

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“What the hell is going on around here?” That’s one of my favorite sideline videos of Vince Lombardi as he’s talking to his players, and that’s the way I felt after watching this movie. As I said, I’m going to cover one of the studies that was cited several times, but there’s a whole lot more science that warrants explanation; it’s available for Members and Insiders as a Straight Talk on Health audio. Now to the study.
 

“A Vegan Diet Is Better Than ADA Diet”

One of the films experts may be recognizable to some readers: Dr. Neal Barnard, president of the Physicians Committee for Responsible Medicine. He’s a leading proponent of a vegan diet. He led a research group that conducted a study to compare a vegan diet with a diet based on the American Diabetes Association diet guidelines (2). In the film, there were several references to the study that claimed it was more effective than the ADA diet—in fact, twice as powerful at controlling or reversing diabetes as the ADA diet, which included meat and dairy.

Researchers gave both groups dietary guidelines to follow for each diet as well as training with a registered dietician; 49 subjects began in the vegan group while 50 began in the ADA group. The study went 22 weeks and then continued through 74 weeks with the subjects tested periodically. I don’t know the significance of the 22 weeks; those results were not included in the paper.

Here are the results that didn’t quite make the movie:

  • There were no differences in the decrease in blood sugar; both diets reduced fasting blood sugar a similar amount.
  • Fewer than half the people in both groups completed the study.
  • The subjects in both groups claimed to reduce their caloric intake over 400 calories per day. However, weight loss was just ten pounds in the vegan groups and seven pounds in the ADA group. Really? In 74 weeks? Those results are simply not possible unless the subjects did not accurately report what they ate.
  • Finally, this study didn’t show that a vegan diet was twice as beneficial as the ADA diet; it showed that they were both ineffective at achieving reasonable goals for weight loss and a reduction in HbA1c over an extended period of time. While it was statistically significant, a reduction from 8.1% to 7.7% in over a year is not much improvement. Yes, it was better than the ADA diet in which the HbA1c stayed the same, but I wouldn’t start touting the benefits for diabetics just yet.

 

What the Movie Did Right

The only expert who comes through this movie unscathed is Dr. Caldwell Essylstein, the physician from the Cleveland Clinic who has demonstrated in a large clinical trial that severe CVD can be reversed using a low-fat vegan diet. I’m a fan of his work and education program. He was in only a couple of scenes and did not corrupt science in anything he said.

No so for many others in the movie. I just don’t understand why these medical and healthcare professionals would say the things they said. I have more to say, and it’s in the Straight Talk on Health audio for Members and Insiders.

What the movie got right was to provide the research that the experts cited in the movie. It was done scene by scene and makes it easy for anyone to check where the experts got their research facts. Unfortunately, that didn’t stop the research from being misinterpreted by people who know better.
 

The Bottom Line

“What the Health” is a mess of a documentary. It’s not an objective examination of what constitutes a healthy diet; it’s a critique of the food industry and health organizations that get funding from that industry. The problem is that it’s not done very well and never quite gets around to proving what it claims. Maybe they’ll do better next time.

I know a vegan diet is a very healthy way to eat if you do it right. We must move to a more plant-based diet if we’re going to be healthy, and it’s better for the planet as well. While I don’t think it’s the only healthy diet, it’s certainly great if you take the time to learn how to follow it correctly. The problem is that the plants we count on for nutrients may continue to have fewer of them. That’s the topic for next weeks Memos.

What are you prepared to do today?

Dr. Chet

 

References:
1. What the Health. Directed by K. Andersen and K. Kune. 2017.
2. Am J Clin Nutr 2009;89(suppl):1588S–96S

 

“What the Health”: False Sugar Claims

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“Sugar doesn’t cause diabetes!” So says just about every expert in the film “What the Health.” Of all the misstatements in the film, this one is the worst and most dangerous. It isn’t because the statement is false; it’s because of the way it’s presented. Expert after expert looks into the camera and says that excess sugar intake does not cause type 2 diabetes. On top of that, the explanations that they give to justify their position are misleading.

One expert said that sugar will be stored as glycogen in the liver and the muscles and the rest used for energy. That’s correct. Another talked about the Duke University Diet which included rice, sugar, and some fruit and fruit juices; one physician used it to help many people who were too sick for other treatments. All the experts filmed agreed that neither sugar nor carbohydrate caused type 2 diabetes. It just couldn’t.

They are stopping short of telling the truth or intentionally misleading the audience. Sugar doesn’t cause type 2 diabetes if the person does not overeat. The statement about glycogen? True, as I said, but when a person overeats carbohydrates, the liver stores as much glycogen as it can and then converts the rest to fat.

Excess carbohydrates lead to insulin resistance and eventually, type 2 diabetes. The Duke University Diet? That was from the 1940s. It was an ultra low-fat diet with no salt, and was used to treat the sickest patients but only under the care of a physician.

The section on sugar and diabetes was by far the worst. It intentionally misleads people to think that overeating is fine as long as it’s carbohydrates. But there was one study that was cited over and over that’s even worse in my opinion. I’ll cover that on Saturday.

What are you prepared to do today?

Dr. Chet

 

Reference: What the Health. Directed by K. Andersen and K. Kune. 2017.

 

Chelation Therapy: Too Soon to Judge

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The results of the study on chelation therapy in subjects with diabetes showed a reduction in cardiovascular incidents during the follow-up time. No single event dominated, ranging from heart attack to stroke to death, but overall there were fewer incidents. Subjects who did not have diabetes did not experience a benefit in v incidents during the same follow-up time.

That led the researchers to speculate why. They couldn’t come up with any specific reason other than the chelation must involve a mechanism that was not yet identified. They carefully suggested that while the results were positive, this study could only suggest that larger clinical trials were necessary and the findings do not constitute enough evidence to be recommended as a treatment.


Should You Do It?

Here a few more things to consider:

  • The cost: each session costs $90 to $150 and there should be at least 30-40 of them. Add office visits and the total price could be around $5,000; none of it is covered by insurance.
  • All the subjects continued to use their typical medications for diabetes, cholesterol, and blood pressure. This was not replacing traditional treatments, it was in addition to the treatments.
  • The investment of time was significant at three-plus hours once a week or on whatever schedule the patient and doctor agree upon.


The Bottom Line

This study demonstrated a small cardiovascular benefit to the patients, reducing the risk of a cardiovascular event from 35% to 25%. In my opinion, the results are too small to justify the cost of money or time.

I know people who swear by chelation therapy, and I’m happy it worked for them, but there’s too much we don’t know. Nobody tracks what is actually changed in the body during chelation. Where do the heavy metals go? What if someone doesn’t process metals the same way to eliminate them? At this point, there are more questions than answers.

Here’s an idea. Spend the money on more vegetables and fruit for your diet. Invest the three hours per week in additional exercise. Both of those things will give you a better return on your investment than chelation therapy.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2014;7:15-24

 

Update on Chelation Therapy

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One of the questions asked during Tuesday’s Conference Call was about chelation therapy for helping with memory. I didn’t find any research to support that outcome, but a couple of studies have been published on chelation therapy with cardiovascular disease (CVD). One paper was from the Trial to Assess Chelation Therapy or TACT study.

Chelation therapy is used to eliminate heavy metals with the goal of reducing the metals that can be toxic to the body. While it’s been used for decades, the research hasn’t demonstrated a clear benefit.

For the TACT trial, researchers recruited over 1,700 subjects. In this paper, they used a sub-group of subjects from the original study who had diagnosed diabetes and had a heart attack more than six months before the study began. Half the diabetic subjects received chelation with EDTA (ethylene diamine tetraacetic acid) as well as some vitamins and minerals. The other half were infused with just saline solution. All subjects were given low doses of vitamins and minerals.

Subjects were infused once per week for 30 weeks and then biweekly and bimonthly until 40 sessions were completed. Each chelation session lasted three hours. With the investment of time, did the chelation therapy result in fewer cardiovascular events over the next five years? We’ll see on Saturday.

What are you prepared to do today?

Dr. Chet

 

Reference: https://doi.org/10.1161/CIRCOUTCOMES.113.000663

 

The Last Word on Sugar

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The sugar war continues in the health headlines these last few days of 2016. Here’s a summary of what was said and my opinion.

Researchers reviewed the science behind the nutritional guidelines that fewer than 10% of calories should come from sugar (1), a position held by the World Health Organization and the USDA. After examining the science behind those guidelines, they concluded that the guidelines are not trustworthy.

Experts responded by calling what the researchers did junk science (2). The researchers were funded by a group composed of soda, candy, and fast-food companies. The experts said that . . .

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Curcumin: Question 3

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Most super herbs and juices come from other countries—açai from Brazil and noni from Southeast Asia to Australia. Curcumin seems to have been used in India for hundreds of years. As we finish this look on questions we should ask about the latest and greatest nutrient, juice, or herb, this is most likely the simplest question of all. Here’s the obvious question: do the people where the herb is traditionally used live longer than we do in the U.S.?

I’ll stick with curcumin and India. Although our official life expectancy just decreased a couple of . . .

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Recent Research: Milk and T2D

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Health news headlines got my attention this past week. They announced that full-fat milk products may reduce the risk of type 2 diabetes and becoming overweight. I don’t know about you, but it’s been decades since I drank whole milk or ate whole-fat yogurt or ice cream. It’s not just about the calories; it just doesn’t seem to taste as good. Have I been missing something? Headlines tend to exaggerate, especially when they’re based on press releases. Let’s take a look at the first study behind the headlines.

In the first paper . . .

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Prediabetes: What Now?

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The messages this week have talked about the risk factors for prediabetes and how many people don’t know what they are. It’s time to change that, at least in those of you who read the messages. Please feel free to pass them along to anyone you feel might also be unaware.

How do you know if you’re actually prediabetic? It requires a blood test for a specific protein called HbA1c. This protein indicates the amount of sugar that’s been in your blood stream for the past 90 days. The number for your blood sugar might be . . .

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