MUST DIabetes be progressive?

When I was diagnosed T2 in 2003, following a stroke, I was put onto 3 x 500mg Metformin per day + 40mg Gliclazide. I was advised( briefly!) on diet and told a week later that since diabetes is progressive, I would gradually need to increase my medication. Initially, the Gliclazide dose would be doubled( I was halving the 80mg tablets at the time) then I would have my Metformin changed to the 850mg tablets and eventually and inevitably, I would need insulin. So far I’ve dropped the Gliclazide completely, whilst reducing HbA1c to 5.6% and losing 40 pounds, which I’ve kept off. I also often miss the midday Metformin tablet&gt: so not going on to the 850s.
I discovered Richard Bernstein, Charles Clark , Lois Jovanovic andDavid Mendosa,. I read everything I could: joined this and one other forum. I also used my education(I have a degree in a Biological Science) I have subscribed online to “The Journal of Nutrition and Metabolism” and “The Lancet” I keep up to-date on research.
I walk miles each week and attend exercise classes in a group of people of my own generation, who all have health issues.( at 62, I’m one of the youngest and fittest.)
The secret for me has been carb restriction.
This used to be the standard dietary advice to diabetics, before the Ancel Keys Lipid/heart hypothesis and the idea of “progression”. I know of at leat one T2 diabetic, who has lived a lifetime, into the 80s on a restricted carb diet and without medication. Have ALL the medics been bamboozled into the pharmacological route for diabetes control? Definitely the medical establishment in the UK have totally committed to it. As a result under 50% of British diabetics achieve an HbA1c < 7.5%.
I am not so naive as to think that aall people with diabetes could or would comply with a reduced carb diet, but many more would if they knew about it.

Keep in mind I’m not a T2, so my perspective is that of a younger T1 just observing what I see in a lot of T2’s… but I don’t think the problem lies completely with the medpros… I think there’s a lot to be said for the patients who just want to pop a few pills and forget that there is anything wrong… many often have relatively poor control and don’t really understand that they’re not taking care of themselves because they’re doing what their doctor tells them to do - THOSE are the types where it is likely to be a progressive disease (in terms of medications required, and difficultly acheiving control), as they just aren’t adequately managing their disease. Poor control leads to complications… which includes the decline in the ability of the beta cells to produce enough insulin to compensate for IR (edidence has strongly suggested that elevated BG damages beta cells). I do think that for some people it may very well be possible to halt the progression of the disease, but it certainly doesn’t happen all on it’s own - it’s something you have to work to achieve (how hard of course, varies).

With a growing understanding of the overlapping of both T1 and T2, and more antibody testing is being done, I think more T2’s are being reclassified as T1.5’s after the realization that there’s something more going on than just T2. In those cases, I don’t think it’s necessarily fair to describe the requirement of insulin as a ‘progression’ of the disease - it is simply the expected outcome. For some the process takes longer, but because it’s an auto-immune process, it’s also not one that can be stopped or prevented - at least not until a cure is found for all auto-immune forms of D. So it can’t be considered a failure in any sense…

There’s another issue that even when enough correct education is provided (I feel in many cases most people aren’t offered enough, or they’re offered outdated information that actual patient experience shows doesn’t work out well - like the infamous ADA diet) it seems to fall short for a lot of people - either they’re needing a different approach that has never been suggested to them (not everyone is as proactive about researching their options… accepting whatever an MD tells them as the final word), or they just choose not to care about what they’ve been told or take any action at all - why bother, since they “feel fine”. That’s the problem… so much of the damage caused is just not obvious until it’s fairly advanced, so people are able to live in denial for a very long time - and for many, by the time they choose to care, it’s too late to stop the complications.

Granted, most diabetics that are here, or any other online forum, are most likely a bit more interested in taking care of themselves than the average diabetic… you get the benefit of current information (that actually helps!) as well as a community of people who are all aiming for the same thing - good control and no (or fewer) complications - in a very effective way, and everyone is able to support each other.

The thing about any form of diabetes is that it’s a self-managed disease… the failure I see is really in many patients expecting their doctors to do everything for them, and micro-manage their care… and that extends far beyond just T2 and into every form of D… it’s a pervasive problem.

I have mentioned this elsewhere on multiple occasions – I believe that “Type 2 Diabetes” is an umbrella term covering a number of etiologically distinct causes of persistent hyperglycemia. We know that untreated, persistent hyperglycemia over long periods of time (years or decades) can result in beta cell death – but it would seem to make sense that this is just one of the various necrotic “complications of diabetes” (such as neuropathy, nephropathy, and diabetic ulcers) – the effect of untreated hyperglycemia, rather than the initial cause. (Obviously, after those cells have been destroyed, the lack of insulin becomes a secondary cause of persistent hyperglycemia.)

One primary cause of persistent hyperglycemia is the insulin-blocking effect of adipokines (or lipokines) – hormone-like substances secreted by fat tissues. In those cases where adipokine action alone is responsible for hyperglycemia, weight loss can improve glucose metabolism – sometimes to the extent that pharmaceutical intervention is no longer required. This would require that said persistent hyperglycemia is mild at diagnosis, or that it is caught early in its course that beta cell function is relatively intact.

Again, in those cases, “diabetes” may not be “progressive” so long as blood glucose levels and weight are controlled.

It would seem to me that – since we learned in biology classes that all nutrients are metabolized into simple carbohydrates (aka glucose) before re-use as human-specific proteins, lipids, and complex carbohydrates – specifically restricted-carbohydrate diets should only be effective in cases where the first-phase insulin response is impaired, but the second-phase insulin response is intact. (Because exogenous insulin has a lag time – even ultrafast insulins such as Apidra have about a ten minute lag – carbohydrate restriction may also work in minimizing the peaks and dips of insulin-dependent diabetes.)

If, however, there are other issues involved – anecdotally, I believe my own first-phase insulin response to be fairly intact, but the second-phase to be somewhat deteriorated – low-carbing may not be the best diet for the individual. Other options – calorie-restricted diets, “smart carb” diets (including various “Mediterranean Diets” and later phases of the South Beach Diet), and whole-food/organic-food diets – may be more appropriate for specific hyperglycemic etiologies. (Just look at the various “what foods spike you?” threads to see some of the range here!)

Regarding pharmaceutical intervention: as of last year, ADA recommendations were to start with Medical Nutrition Therapy (i.e., diet and exercise) before progressing to pharmaceuticals (usually metformin). At the time I was diagnosed (tomorrow will be 7 years), I asked my doctor and she had said the standard protocol (at that time) was to use oral pharmaceuticals to restore normal glucose metabolism and then to adjust the medication class and dosage as necessary. In retrospect this makes a degree of sense, as not everyone is willing or able to adjust his diet, and it is the persistent hyperglycemia that is responsible for diabetes-related tissue damage. What one needs is a medical team that will emphasize the role of diet over medication and that is willing to reduce the medication load as the patient’s condition improves.

Obviously Big Pharma wants more of us medicated up the wahzoo – but since the initial medication of choice is usually a generic (metformin, standard or extended release), Big Pharma isn’t getting all that much money from starting us on “the usual drugs”.

As medical practice methods of diagnosis and underlying etiologies improve, I would expect the underlying causes of nonautoimmune persistent hyperglycemia to be differentiated, and for the appropriate pharmaceuticals and nutritional guidance to be provided shortly after that diagnosis.

The first thought in most British PCTs ( health authorities) is where to save money. They pay lip service to improving patient care, but when it comes down to it, the cost of medication wins. my own PCT in West Berkshire, admitted at an “event” which I attended that it’s not allowing Liraglutide on cost grounds and it’s already harder to get Byetta than blood out of a stone. I can’t get more than 100 test strips per year without begging and pleading from my doctor. I just buy my own now. I would never qualify for any of the more expensie medicines.

Hi there. I’m a little younger than yourself, but I find that I was able to control my T2 the same way you are doing it. But I couldn’t keep up that lifestyle. The minute I put more than 100 gms (and even that was a lot) of carbs in my mouth and didn’t keep up the pace of exercise I started upon diagnosis at 28, my body became so insulin resistant, I had to practically do cartwheels to keep off the weight. I couldn’t keep up with it.

I agreed with you back when I was that age. What’s the rush to write the script. But even as I kept my a1c below 6 and did all the right things and considered myself pretty well-controlled, the silent effects began. HBP, hi TGs, low HDL, liver enzymes creeping up, etc…

You are right - if more people knew about how to control their diabetes, we may not rely as heavily on drugs or we may prolong or delay those effects, but I also know that if you are diagnosed T2 as early as I was, it is HELL to keep up that lifestyle (as I’m sure T1s could most likely vouch for) for so long, unless that was your lifestyle before dx.

I’m not saying give up or give in or become a couch potato because you can’t control it. I’m just saying live with the notion that this disease IS progressive, because if we don’t, we become complacent and tempt fate (I know I did).

Embrace that fact, employ yourself with knowledge, do all the right things, but be willing to accept help when the time comes, and be so good to be a great advocate for yourself so perhaps you can limit medication.

I can certainly say that all the medical professionals I have seen have definitely not been bamboozled by the pharmacological approach - in fact, in my experience, my medical professionals waited too long to enact that approach.

I think that there are psychological effects and approaches with this disease no matter what Type you are - and those have to be taken in consideration as part of the treatment.

Good discussion - thanks for bringing that up!

Jill

Brenda: I always enjoy reading your posts. I have learned SO much from you. Thank you for all your contributions!

Jill

Diabetes is not a one size fits all disease. There are so many variables, with the disease itself and with people’s personalities, habits, lifestyles, levels of understanding, levels of ability, otehr health complications, standard of living, etc., all of which impact diabetes.

So, I don’t diabetes is always progressive. But I do think it often is, for so many different reasons.

I’m type 1, so will always use insulin. By following a diet carb-rich in fruit, vegetables and grains, with limited amounts of meats and very little fat, I’ve reduced my total daily insulin dosage by over 30%.

Hi Jill, I would never eat 100g of carb in a singgle meal. Most weeks It would be a whole week’s worth.
Today, I’ve had a tiny bit of birthday cake, about the size of a walnut

Some months ago, I participated in a focus group paid for by the people who manufacture Byetta. Throughout the discussion, the facilitator kept harping on the “progressive” nature of the disease & I kept fighting that characterization. But, I now freely admit that what worked for me upon diagnosis 10 years ago doesn’t work now. In fact, in addition to oral meds, in January I added long-acting insulin to my routine. I am not less compliant than 10 years ago. I know much more now because of my own research (not because of information my healthcare providers have given me) about how to manage my BG. And, everyone who knows me says that I am very disciplined in my approach. Still, I am 10 years older, still very active physically, but on 1000 mg of metformin twice daily versus the very low dose I started on, and in those 10 years, I have tried glipizide, Januvia, and others without success. I was suspicious that I am LADA, but GAD antibody testing and c-peptide results ruled that out, according to my endo. No one else in my immediate family - neither parent, no siblings, no grandparents until over age 65 - ever had this issue. I now accept that proper diet, exercise, and medicine will not continue to work the same over time. So, I regretfully affirm that, for me at least, it is a progressive disease. That doesn’t absolve me from my personal responsibility of doing the best I can to manage it.

I agree with Maureen about the variable nature of this disease, and the danger of making general statements. But from what I have read and heard on these boards, diabetes does progress in a number of ways. I think there is more variation and progression if you will for Type II’s and Type 1.5’s. A Type II may start out being able to control BG with just diet, exercise and weight loss/maintenance. Some do an amazing job at this and I believe they buy themselves time but eventually need oral meds and eventually (over 10-15 years) progress to insulin. For us 1.5’s we progress more quickly but are often misdiagnosed initially as Type 2 because we can maintain on oral meds or even just diet and exercise. But this time is measured in months or a few short years before we no longer produce sufficient insulin and become insulin dependent.

The Type 1’s on the board can chime in but I think there is less “progression” there because they start out with insulin dependence. Unfortunately, some Type 1’s as they age, and especially if they submit to the philosophy of eating anything they want and covering it with insulin can in time become insulin resistant and so have that issue to deal with in addition to their insulin dependency.

I think the important thing is to stay away from equating “progression” with “failure”.

What do you eat Barrie?
I believe that modern dietary advice( since about 1980) contributes to “progression”. In the early days of Insulin, a restricted carb diet was prescribed and a few people from then have done very well. Only a few, because time has whittled them away.

I’m pretty low-carb, as most root veggies, pastas, rice, corn, & bread cause spikes for me. Since I have learned more about BG management, I actually eat much better, I believe. The majority of my carbs are in fresh fruits (mostly berries) & green vegetables. I eat some nuts every day. The only dairy I can manage is yogurt & low fat cheeses, as I really don’t like milk & stay away from ice cream. For quite a while, I ate according to phase 2 south beach, but even the whole grains got to me. Any suggestions?

I’m 59 and determined to enter my 60’s with a lower hbA1c in the 5’s. I eat moderately low carb 50-100 carbs a day. Some days are better than others. I use Bernstein as a framework but add berries and low carb bread and potatoes with the peels once in awhile. I exercise almost everyday using barbell and weights and walk 4 miles on alternate days. I take 850, 2 x of metformin but still have problem with morning numbers ( today 117) I’m healthier now than I was 20 years ago. I’m about 5 pounds from my goal weight ( 125) and very muscular for an almost 60 year old. I don’t think progression is inevitable.

This sounds pretty good, but I’ve discovered that we need fats if we cut the carbs right back. Recent research shows that the only truly BAD fats are Trans fats. There’s nothing proven against saturated( mostly animal) fats. After all why should plant oils be better for us than animal fats, since we are animals and largely carnivorous in our evolution?

have you looked at the paleo diet?

No - per day.

Great point, Zoe. And Barrie - same feeling here. If I don’t equate progression with loss of control, just chalk it up to the nature of the “disease” or “condition” as it were, I feel less guilty and at fault.

I will have to admit, as I rounded the bend toward 40 and watched my D control slip from my grasp, I did tend to blame myself, and then I went into that rut of oh, well, nothing is going to help, might as well enjoy myself.

I think we owe it to all of our fellow T2’s to admit that. We all suffer from diabetes burn-out, regardless of type, but I think it’s especially important for us older T2’s to admit to our newly diagnosed friends that even though we may have done everything right, we are not in control - our D is.

So the best thing to do is to keep up the healthy lifestyle with no promise of reward, and accept help when we need it, without admitting fault or succumbing to our self-fulfilling thoughts of failure.

Now, if I could only take a dose of my own medicine there! :slight_smile:

I found that the ADA recommended diet was too high in carbs for me. I have found the mediterranean diet works better for me. Someone ahead of me here talked about the Native American Indian adjustment to the Super-Size diet has been a catalyst for more diagnosed diabetes in that culture. I think that definitely this is evolution at its typical - my Scandanavian culture was very low fat protein (fish) and more complex carbs. I think that as we gravitate toward a high refined carb process trans fat diet, we will see more cultures develop diabetes as an epidemic.

I just read a statistic that may apply to the OP’s question … and it gives me a question of my own: If as Joslin’s states, 5 - 30% of those iniitally diagnosed as Type 2 are actually LADA, do the studies on the progression of Type 2, and presentation of stats thereof, also include that percentage of LADAs? In which case, it would seem to me that perhaps far fewer Type 2s will progress to insulin dependence, than is predicted by the data.

I have certainly come across a number of people diagnosed T2, who ended up very ill with DKA, because they were LADA. the Medics seem to make the assumption that any new adult case is T2. It’s still a small number overall. Thing is “progression” is slow, over a span of years perhaps 10 to 15, but developing DKA, because you need insulin, is usually fairly quick. I know of one case which took 4 years to diagose correctly, but not any longer.