Breaking News – Does Tight Control Help or Harm Diabetics?

I don’t usually rush to report on news when I first hear about it, and in fact, there is a great deal of news that I don’t even bother discussing in my blog.  When I do discuss studies, I like to have time to think about them first.

But the news this morning that indicates that diabetics who “control” their A1c levels die faster than those who don’t has me fuming.  And when even friends who don’t read my blog, don’t even know that my blog exists, start shooting me e-mails with the “news,” I feel like I have to say something quick.

Here’s the article from the New York Times.  I haven’t yet read the study, but the article, which is probably largely cribbed from the press release, the way so much media science coverage is, gives me pause.

One thing that really jumped out at me was the discussion of just how A1c was “controlled.”

“Many were taking four or five shots of insulin a day,” he [Dr. John Buse, the vice-chairman of the study’s steering committee and the president of medicine and science at the American Diabetes Association] said. “Some were using insulin pumps. Some were monitoring their blood sugar seven or eight times a day.”

They also took pills to lower their blood sugar, in addition to the pills they took for other medical conditions and to lower their blood pressure and cholesterol. They also came to a medical clinic every two months and had frequent telephone conversations with clinic staff.

I love the way the article says, “This is what you must do to get normal A1c.”  No, no, no!  You can get normal A1c by drastically reducing carbohydrate intake – many diabetics who have tried this find they can get normal readings with little or no medication.  But of course, if the guy you are consulting is a shill for the ADA, which is in turn in the pockets of the pharmaceutical companies, of course your news report is going to suggest that the only way to get good A1c control is to down lots of pills.

So, why did so many more people with tight control die?  Not having looked at the study, I can’t say, but I have some hypotheses.  Cholesterol-lowering medications are toxic; they cause neurological problems, muscle weakness, and stroke.  Blood pressure medications are notorious for increasing insulin resistance, and conversely insulin raises blood pressure by instructing the kidneys to retain sodium – a vicious cycle.  Avandia, an oral hypoglycemic, is linked to heart disease, and that’s just the one we know about.

Of course people who take all this crap die sooner.  This is why it is my goal never to have to take any of it.

The safest way for a diabetic to maintain A1c levels at normal levels is carbohydrate restriction.  This will also control blood pressure (because of insulin’s sodium-sparing effect), and has been shown repeatedly to raise good cholesterol and lower bad cholesterol.  It also lowers triglycerides, which are a much better predictor of heart disease than pool ol’ cholesterol.  A low-carb diet also reduces the production of advanced glycosylation end products (AGEs), hybrid chemicals created by the joining of a carbohydrate molecule to a protein molecule.  AGEs are thought by some researchers to be the cause of the damage to small nerves and blood vessels that leads to so many complications of diabetes, such as blindness, heart disease, gangrene, kidney disease, and neuropathy.  I wouldn’t expect a high-carb diet that is “controlled” with medication to reduce AGEs, because one is still consuming lots of glucose.

So the conclusion I draw from this is:  put down that darn piece of bread and eat some spinach.

Unfortunately, the conclusion the press, and most of its readers, will draw from this is:  don’t bother keeping your A1c (itself a glycosylated protein) under control.  Irresponsible!

Early Detection Double Standard

Every year, my doctor does a Pap smear and sends the results off to the lab.  If the results come back abnormal two years in a row, here’s what will happen:

• I will go to a specialist for a colposcopy, in which my cervix will be carefully examined under magnification and vinegar (really) to detect any abnormal cells.  Abnormal cells will be biopsied, and it is quite likely that a tissue sample will be taken from inside the cervix.
• Assuming that the results come back negative for cervical cancer, for the next several years, I will have semiannual Paps done by a specialist until no more abnormal cells are found.  Then I can go back to annual exams done by my primary doctor.

This is all done to make sure that abnormal cells, if present, are found, and to carefully monitor those abnormal cells so they can be excised if they show signs of becoming cancerous.  Early detection is widely thought to be the most important determining factor in successful cancer treatment.  And certain kinds of cancer screenings, such as Pap smears, mammograms, colonoscopies and prostate exams are routinely done on all patients over a certain age regardless of family history of cancer.

On the other hand, every year, I ask my doctor for a fasting glucose tolerance test, and she tells me that on my last routine blood workup my fasting blood glucose was normal and refuses to order the test.  (This year she offered to do another fasting BG, which I declined.  I know my FBGs are OK.)  She acts thus even though I have several risk factors for diabetes, including a family tree absolutely riddled with diabetes.

What happened to early detection?  Is my doctor guilty of malpractice?

Not really, at least not by any standard that would be acceptable in a court of law.  My doctor’s practice is part of a giant teaching hospital affiliated with one of the most prestigious medical schools in the country, and furthermore, this hospital is the home of one of the leading diabetes programs in the country.  And, according to my doctor, the hospital’s definition of diabetes is two consecutive FBGs above a certain number (which is, I think, 126 but may be higher.  I wish I’d written it down).  My FBGs are always well below 100, so no concern about diabetes is indicated.

My doctor is not being negligent; she’s following well-established diagnosis guidelines.

The thing is, I think she’s right and she’s wrong at the same time.  FBGs are a sufficient indicator of full-blown diabetes.  They are just lousy as an early detection standard.

The National Diabetes Information Clearinghouse indicates that the glucose tolerance test is more sensitive for diagnosing pre-diabetes than FBGs.  And the simple reason one would want to diagnose pre-diabetes, according to the same organization, is:

In pre-diabetes, blood glucose levels are higher than normal but not high enough to be characterized as diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Pre-diabetes also increases the risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.  (Source:  National Diabetes Information Clearinghouse.)

It’s all about early detection, kiddos.  The Massachusetts General Hospital Diabetes Unit says, “High levels of glucose are toxic to beta cells, causing a progressive decline their function and cell death.  Consequently, many patients with type 2 diabetes eventually need insulin.”  You don’t have to be Aristotle to derive the syllogism here – those with pre-diabetes who do not receive a diagnosis can expect their beta cells to become poisoned by their high blood sugar levels, eventually leading to full-blown diabetes and possibly even dependence on insulin injections.  Why wouldn’t one of the premier diabetes centers in the country want to detect this early?

I have a lot of ideas about why, most of them sinister:

• The GTT is more expensive than the FBG, and doctors, who are paid by insurance companies, have an incentive to save money.
• Doctors don’t know that lifestyle changes can reverse pre-diabetes.
• Doctors do know that lifestyle changes can reverse pre-diabetes, but, misinformed as to what those changes are, prescribe ineffective low-fat diets.  After years of seeing patients fail to reverse diabetes on low-fat diets, doctors give up on lifestyle changes.
• Doctors not only know that lifestyle changes can reverse pre-diabetes, they even know that carbohydrate restriction is the way to go.  But doctors don’t believe that patients can make and stick to such “drastic” lifestyle changes as giving up bread.
• The research hospitals that set the guidelines for diagnosis and treatment are funded in great part by pharmaceutical companies, and therefore have an incentive to recommend a course of action that results in a medication-dependent population.

To be fair, Jenny at Blood Sugar 101 (formerly called What They Don’t Tell You About Diabetes) offers a somewhat more benign explanation:

• Decades ago, when diabetes treatment was less sophisticated, a diabetes diagnosis was not only a death sentence, it would prevent a patient from getting insurance or even a job.  Since it was thought that nothing could be done to reverse elevated blood sugars, early diagnosis was worthless and could cause financial problems for a patient.  It was deemed a kindness to delay diagnosis as long as possible.  (See Jenny’s article here for lots of fascinating information.)

The drug and insurance company problems seem tough to solve without a gigantic social upheaval.  But surely our doctors can do better!  Doctors do push back on ordering expensive tests, and patient advocacy organizations do lobby Congress to make insurers pay for certain kinds of tests.  It would be the rare insurance company that fails to pay for routine Paps, mammograms, colonoscopies, etc., even though some of these tests are rather pricey, much pricier than a GTT.  And surely doctors can shed the fatalist attitude - sure, many patients would rather jab themselves with insulin than give up their donuts, but that does not mean that every patient would.  I myself grew up watching my mother inject herself with insulin first once a day, then up to four times a day, and even though she became very callous (pun intended) about it, and even though I can submit quite stoically to needles in a doctor’s office, I am too chicken to inject myself.  Anything I can do to avoid that necessity, I will do.  I am surely not the only patient out there who would rather give up bread than poke a needle into my thighs several times a day!

Why don’t doctors give us choices?

It’s all in the presentation.  A doctor can say, “There’s nothing I can do for you but give you a drug,” because he assumes that the patient wants a quick fix.  Or a doctor can say, “I can give you a drug, or you can give up your favorite foods; your choice.”  Or a doctor can say, “I can give you a drug, but if I do that you are going to need more and more medication as time goes on; you will experience side effects that might be bothersome or even dangerous, and it will cost you a lot of money; or you can follow a diet that requires you to give up some foods you might currently enjoy a lot, but it offers you a lot of other delicious, nutritious foods; the diet will keep your condition in check for a long time without side effects, and it may cost you a bit more than what you spend on food now, but it’s cheaper than drugs.”

One more thing – when I was corresponding with my HR department about the company’s support of the American Diabetes Association, he mentioned that he’d personally talked with a number of employees who had been astounded by their diabetes diagnosis, since they’d had no indications whatsoever they were on that path.  Astounded!  Didn’t these folks have the right to know where they were heading, and the right to make a choice on how to proceed based on scientifically sound information?

And finally, if you’re not sick of this topic, please check out this post on Jenny’s Diabetes Update blog.  (Yes, this is the same Jenny who brought you Blood Sugar 101.)  Read the post comments, too.)

When Inderal Meets Low Carb

I’ve commented before on how disturbing Inderal dreams can be.

Last night I dreamed I was eating in my college dining hall.  I had half an English muffin.  Then I went back for the second half.  Then I had a croissant.  Then a bagel.  Then another croissant.  You know where this is leading, don’t you?

I’m sure the “fat is all in your head” camp will say that this is because I miss these foods.  On the contrary, this was not a dream of desire.  It was a nightmare.  It was like I dreamed I was eating poison.

Neurology Appointment on Wednesday

Long-time readers of this blog may remember that about 3 months ago, I tried to make an appointment with a neurologist who specializes in migraine, and was told that he was booked until late October.  I made the appointment, my PCP prescribed Inderal, and I haven’t had a migraine since.

I’ve been wondering whether I should keep this appointment, since I’ve been completely migraine-free since starting Inderal, and perhaps I could free up the appointment for someone who really needed it.  I decided to call and describe the situation.  The receptionist talked me out of cancelling, saying that I should come in and be evaluated, because if I cancelled the appointment and later started having migraines again, it would be another 3 months before I could get an appointment.  “I see this happen all the time,” she said.  If the doctor had evaluated me and the migraines came back, he could consult with me by phone if necessary.

OK.  I did not cancel the appointment.  It’s probably for the best.  I want to ask if he’s heard anything about ketogenic diets for migraine (thanks to all my readers who have provided information sources, by the way).  I’m also more than a little concerned about Inderal’s affect on insulin levels, but it seems to be working so great against migraine that I’m reluctant to stop it without asking some questions.  I want to ask him exactly how Inderal works, and whether there are other drugs that affect the same brain pathways without raising insulin levels.  And of course, if there are other drugs, I want to know what side effects I could expect.  Finally, while this isn’t a problem at this time of year, Inderal is somewhat bothersome during hot weather, when my normal, non-drug-influenced BPs already run a little low; it would be nice if I could find an alternative before next summer – I felt limp for much of July and August.

I’ll confess that what I want to hear is:  ketogenic diets work extremely well for migraine; there’s a high likelihood that I won’t need Inderal as long as I stay on a low-carb regimen; and if low-carb does not completely resolve the migraine situation, there are other prophylactic drugs that do not raise insulin and have very few side effects.

Yeah, right, I can hear my fellow migraine sufferers say.  Well, a girl can dream, can’t she?

Bill Maher Nails It

Today, I spent much of my day reading Protein Power by the Drs. Eades.  I’d never read it before, and it really highlighted not only how much we rely on prescription drugs to treat diseases that are caused by lifestyle, but just how much prescription drugs actually make lifestyle diseases worse.  Example:  you eat a lot of carb, your insulin levels go up, causing you to retain water.  Your blood pressure goes up.  Your doctor prescribes a beta blocker and a diuretic, which get your blood pressure somewhat under control, but also raise your insulin levels further, causing you to gain weight.  Your blood lipids go up, so the doctor prescribes a statin, which causes your insulin to go up, and the next thing you know, you’re a Type II diabetic, and you’re lucky if your doctor even knows how to treat Type II correctly.  (Should you get insulin?  Metformin?  What diet should you follow?  The answers to these questions depend in part on whether your body can actually still produce insulin, but judging from the experience of friends, it can be very hard to get a 5-hour GTT, and when you do get it, half the time the techs don’t measure your insulin levels.)

So I was quite delighted to find a link to this video in my inbox.  I’ve often remarked that the only two reliable news sources in America are The Onion and Jon Stewart.  Why is it, anyway, that only comedians can tell the truth in our world?  Is it because that bit of laughter is the sugar-coating (whoops! I mean “pat of butter”) that makes the bitter truth go down better?

Oh, and add to my previous list of things we can all agree on:  fried Coke is bad.

Flickering

After the alarm clocks went off this morning, but before we actually got up, I asked my husband if he could see flickering light.  (We live on a busy street, and there’s a tree outside our bedroom window, so sometimes the combination of reflections on moving cars and light filtering through moving tree leaves creates an impression of flickering.)

“No,” he said.

“It’s weird,” I said.  “I don’t see it either, unless I hold my head at a specific angle.  Then it’s like there’s a slight flickering light on the bridge of my nose.  It’s almost like the sensation you get when you’re in a room with a ceiling fan, and the fan is at the very edge of your peripheral vision.”

Actually, I thought, it just like the last stages of migraine aura, where the little dot of disturbed vision has expanded to a ring of disturbed vision, and the ring has expanded and expanded until it’s mostly out of your field of vision, and then it’s gone.

It wasn’t aura, at least not as I usually experience them.  First of all, I had been awake for at least 10 minutes, and had not noticed the usual progression of aura described above, just flickering on the bridge of my nose.  Second, it went away when I closed my eyes, which aura never does.  And third, no headache followed.

Even though Inderal seems to be a godsend in preventing my migraines, I still live in fear and vigilance.  My husband’s parents are visiting and took lots of photos yesterday.  I monitored the flashbulb afterimage carefully, because these afterimages are bit like aura.  I still occasionally get very minor headaches that may or may not be sinus headaches, and I wonder if each headache is going to be a mere annoyance, like a fly buzzing around, or if it’s going to send me running to a dark, quiet room to hide.

I didn’t feel this way when I was a teenager and had a handful of migraines a year, mostly clustered in the spring.  And I didn’t feel this way when, in my twenties, I started to realize that my last migraine had been at the age of 18.  And I didn’t feel this way during the 19 years when I was completely migraine-free.  But something about my recent experience of having several migraines a month, combined with the fussy nature of Imitrex (“take at first sign of migraine” means “pay attention, dammit, because if you dick around too long waiting to see if it really IS a migraine, you might be too late”), combined with having adult responsibilities like a job, and operating a motor vehicle safely, and doing my fair share of the work to manage a household, has made me very, very twitchy when it comes to migraines.

Inderal Dreams

Saturday night I dreamed I woke up with an aura.  It looked just like the aura shown in my user pic, which means it was kind of abstract, but not too much so.  In the dream, I immediately got up and stumbled down the two flights of stairs to the kitchen, where (in the dream) I kept my Imitrex.  Then I went back up stairs to bed, and thought, “Oh, wait, I have to call in sick.”  I turned, and there on my bedside table was my laptop, already booted up and logged into the network.  I pinged J., my project manager, on IRC, and asked him to tell everyone else.

Then I woke up and couldn’t remember if I had taken my Inderal the night before.  Still can’t, actually.  Given my low blood pressure, I thought it was better to risk skipping a dose than to risk doubling up on one.

No actual migraine ensued, by the way.

This is the third or fourth time I’ve awakened to wonder, Did I take my inderal last night?  I think I’m going to have to put it in one of those 7-day pill counters (even though I only take one daily med).

Inderal, it is said, can cause vivid dreams – in fact, on Friday night I had a rather disturbing dream about my cat.  But vivid dreams about migraines?  How self-referential!

Why Americans Spend More on Health Care

In the light of my recent criticism of the ADA’s position that diabetics should eat a diet that, by the ADA’s admission, raises blood glucose and then cover it with additional medication, this article on the truffulaseed blog caught my attention.

I will not comment on the question of smoking, except to say that after my recent vacation in France it is truly hard for me to believe that Americans – or anyone else on the face of the planet -smoke more than the French.  I can’t comment on other European countries.  As for obesity, there’s no question that Americans have unhealthy habits, but who’s to blame for this? For every person who just doesn’t care, who sits on the couch night after night with a pint of Ben & Jerry’s, surely there is someone following the official guidelines of the likes of the American Diabetes Association, the American Heart Association, and the National Heart, Lung, and Blood Institute to cut out fat from our diets and substitute carbohydrates – and despairs because they are still fat.  The article then goes on to comment that the new Medicare bill prohibits negotiations with drug companies to keep costs down.

The ADA wants diabetics to take more medication; the Republicans want to pay Big Pharma whatever they ask for drugs most of us wouldn’t need if we ate properly; and a number of the most respected health organizations in the country tell us to eat the crap put out by the agricultural-industrial complex despite any evidence that this food is good for us, and despite all the evidence that it’s very, very bad indeed.

I’d say that, once again, we’ve gone through the looking glass, except that suddenly it all makes sense.  There is money to be made, big fat giant obscene wads of money, by selling Americans foods that make them fat and unhealthy, then selling them expensive medications that promise to reverse the ill effects of a poor diet.

This is one of the things that pains me about the obesity epidemic – everywhere we turn, we hear that Americans are gluttonous, lazy couch potatoes.  Why is it so rarely considered that we’re just the victims of bad nutritional advice?

How Do I Make This Decision?

The Dilemma:

On the one hand, I have a dozen or so health problems, major and minor, that seem to be related to a futzed-up insulin/endocrine system:  PCOS, excess weight (though with a BMI of 27.5, I am not clinically obese), neuropathy, joint pain, acne, and apparently even my cracked heels.

On the other hand, Inderal, that fabulous, fabulous drug that has kept my migraines completely in check for the last 99 days (99 migraine-free days!  after having a migraine 2 to 6 times a month for several months, this is like a miracle) has as one of its side effects increased insulin resistance.

I know that insulin resistance that is induced by a high-carb diet can be treated with a low-carb diet.  I wonder – can insulin resistance that is induced by a drug also be trated with a low-carb diet?  Because if it can, there’s no dilemma – keep taking the Inderal, keep avoiding sugars and starches, and all will be well.

But if it cannot, how on earth do I decide between the misery of migraine and the misery of insulin-related disease?  Diabetes is rampant in my family, and I have seen first hand its ravages.  Truthfully, I’d rather have migraine, even several attacks a month, than lose a foot, a finger, or a kidney.

I hope it won’t come to that, though.

All Quiet Here

Well, actually things are not quiet, exactly – we bought a house and moved all our stuff over the course of 36 hours, then I headed off to god-forsaken Orlando (yes, in August) for a conference that is a total waste of my company’s time and money to send me too.  Now it’s budget time at work, which is a huge pain in the ass, and I’m trying to paint, and … and … and …

But it’s quiet in the sense of, no migraines.  Hooray!  More than 60 days on inderal, and it still seems to be working.  I’m a little tired and weak in the heat, but hey, this is Boston – it was actually chilly this morning when I woke up.

I’m seeing the endocrinologist on Thursday; maybe I’ll have news to report then.