The difference between cure and control in T2

Type 2
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Here’s and interesting blog post about a little experiment that demonstrates that control is not a cure in T2 :confused:

The author who is a health care professional adopted carbohydrate restriction in response to a T2 diagnosis. Eventually when her A1C reached 5.0 her doctor said he was going to remove T2 from her diagnosis list because in his words “you’re just not diabetic.” She was glad to have T2 removed but she knew it wasn’t really true.

Recently she had the chance to wear a CGM and decided to conduct a little N=1 experiment, its “eat to your meter” on steroids :muscle:

Here’s one part of the experiment in the authors own words

I decided to do a meal that follows typical diabetes advice, yes, 60g of carbs in one meal. I decided to eat no other carbs that day so I would still end the day eating very low carb, but I ate the entire 60g in one sitting. In addition, I ate processed and refined grains and about 3 bites of something sweet (“moderation,” lol).

Hold on to your seats folks.

This meal included meat, salad, and refined grain products. Here we are.

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Oh no, she’s not cured after all :hushed:

The blog post is very well done, the author conducted several other experiments using the CGM which are very enlightening. I encourage you to read the whole blog post

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Existentially absurd that something which should be logically obvious has to be proven, again and again. And some people still will argue it. Sigh.

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I knew this but it still startles me somewhat when I read this.

And here’s the thing folks. The reason those 60g of carbs per meal recommendations were made, is because it is not unusual for the average American to eat 150g to nearly 200g of carbs in a meal.

Until I accepted the fact that diabetes is a disease of carbohydrate intolerance, I could not consistently control my blood sugar levels. The fact that much of the professional medical advice still counsels, “shoot-up, carb-up” amazes me. In other words, eat all the carbs you want, just take the medication needed to cover it.

I think this might make more sense to someone who has not actually lived with diabetes. I just think that the medical professionals should listen more to those of us who use carb restrictions as a viable and successful way to live well with diabetes instead of dismissing us as non-credible sources.

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There is also the fact that when on low carb, an ingestion of higher carb will trigger a higher BG, diabetic or not.

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Of course, the really puzzling problem with type 2 diabetes is that the Accord study and numerous investigations following it have established that very strict control in that group, going for an average A1c below 7.0, is actually more harmful than helpful. So is it the insulin treatment which is causing the greater harm at this improved level of control or is it something about the patient’s physiology which cannot tolerate near-normal blood glucose levels? If the latter, then control of type 2 diabetes would not be a cure.

The most interesting question, which medicine seems afraid to touch, is whether this improved level of control is also harmful for type 1 diabetics? If it is the action of insulin in achieving this degree of control which is harmful, it should be, since in the strict control group of the Accord study the patients were using insulin to achieve it.

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Actually—no.

The ACCORD study, besides being itself flawed, was shamefully misreported in popular media. Reports had it that people in the study were dying at an unexpected rate. That part is true. What wasn’t as widely reported was that the people who were dying at disproportionate rates were chiefly those who failed to get their A1c below 7.0 and who had been noncompliant and poorly controlled for years before participating. And that’s only one of the misinterpretations applied to ACCORD; there were others. This has been written about extensively in the DOC, both here and elsewhere.

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Seydlitz - David gave some good info but I will say it stronger. Take the ACCORD study and throw it in the trash. Finally after seeing CGM data for a number of years now and seeing actual data the diabetes community is finally starting to catch up on what some have known for a very long time. The BeyondA1c forum this year finally was pushing much tighter range.

The ideal BG target should be 75-140 and <90 three hours after eating. Maintain 140+ for even a few hours causes microvascular damage.

The big issue is current T2 orals can’t keep that range and many T2s spike 200+ after meals without insulin. If the industry says 75-140 they are basically saying don’t take the orals.

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Such an old subject. Not sure why it has to keep coming around…Except that there are so many of us newly diagnosed always…There will be a “cure” for T1 long before a “cure” for T2…The very best we can do with T2 is Tight control, which means minimizing your carbs…I eat 25-30 carbs per day and have done so for a couple decades…My A1cs are consistently in the 5s…Period!

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I wouldn’t dismiss the Accord study too quickly. It was a massive survey of more than 10,000 patients, in which the negative outcomes in the strict control group were so dramatic that it was deemed unethical not to stop the study early. This is far from confirming that strict control actually has any benefit for all the burden it involves. Of course, as soon as it came out, there were efforts to escape its implications, since it threatened the established explanatory paradigm of the development of complications, and philosophers of science from Kuhn to Lakatos have described how scientific theories fight against departures from their established views. It also endangered the profits of the huge diabetes control industry, as well as challenging the reputation of the medical community.

But the scientific evidence hardly indicates that the study is simply worthless. The Accord study, the Action in Diabetes and Vascular Disease study (Advance), and the Veterans Affairs Diabetes trial (Vadt) all came to the same result, “that intensive control to near normoglycemia had either no, or potentially even a detrimental, effect on cardiovascular outcomes” in type 2 diabetes. (1) In 2012, it was evident that a “five-year follow-up study confirmed the earlier observation of an increased mortality signal in the intensive treatment group.” (2) Again in 2012, another review still concluded that “intensive glycemic therapy is rarely, if ever, justified in Accord type patients.” (3) The American Diabetes Association recommendation of less stringent A1c targets for type 2 patients “who do not achieve an A1c less than 7% in the face of ongoing diabetes self-management education and effective doses of insulin in combination with, for instance, with metformin,” was again confirmed. (4) One of the most extensive reviews of the research found in 2011 that “sufficient evidence exists for an absence of a 10% relative risk reduction in all cause mortality with intensive glycaemic control in patients with type 2 diabetes,” as well as insufficient evidence “for a 10% relative risk reduction in cardiovascular mortality” in this group. Further, it found “insufficient evidence to support the conclusion that intensive glycaemic control prevents the occurrence of microvascular disease assessed on a composite outcome, retinopathy, or nephropathy,” but it did find that intensive control caused a 30% increase in severe hypoglycemia in type 2 patients. (5) The Clinical Practice Guidelines of Diabetes Canada, updated in 2016, carried forward the Accord conclusions, noting that “less stringent A1c targets … may be appropriate in patients with type 1 or type 2 diabetes with any of the following … : a) limited life expectancy, … d) multiple comorbidities, e) history of recurrent severe hypoglycemia, … longstanding diabetes for which it is difficult to achieve an A1c less than or equal to 7.0% despite effective doses of multiple anti-hyperglycemia agents … .” So, in effect, they are saying that for some patients at least, the potential negative interaction with various background factors of intensive blood sugar control may well outweigh the benefits.

Of course the Accord study data has been mined to try to find what factors correlate with those patients who are most likely to be harmed by strict control. Generally, it seems that strict control may help newly-diagnosed patients, but may do more harm than good in those who have had the disease for a long time. (6) If there are already other health problems present, this increases the odds of a negative outcome for strict control measures, as does more frequent hypoglycemia. One intriguing study has suggested that those patients for whom strict control may be particularly bad share a genetic trait which makes intensive glucose normalization efforts harmful, and that was published in 2016. (7)

Generally, there is some disconnect between better blood sugar control and a reduction in the incidence and intensity of diabetic complications. For example, in the DCCT study, 40% of type 1 patients with an A1c greater than 9. had no retinopathy after ten years of follow-up. (8) One study of type 1 diabetics surviving more than 50 years with the disease found an average A1c among them of more than 10! (9) The strongest predictive factor for type 1 diabetics developing coronary artery disease is not A1c but the magnitude of their insulin requirement. (10) So even in type 1 patients, strict and poor control don’t exactly match the expected results.

  1. A. Brown, “Intensive Glycemic Control and Cardiovascular Disease: An Update,” Nature Reviews Cardiology, 7, 369 (2010).
  2. Andrew Krentz, “Drug Therapy for Type 2 Diabetes,” London: Springer, 2012, p. 13.
  3. S. Genuth and F. Ismail-Beigl, “Clinical Implications of the Accord Trial,” The Journal of Clinical Endocrinology and Metabolism, 97 (1) 41 (2012).
  4. J. Buse, “Glycemic Targets in Diabetes Care: Emerging Clarity after Accord,” Transactions of the American Clinical and Climatological Association, 126, 62 (2015).
  5. B. Hemmingsen, et al., “Intensive Control for Patients with Type 2 Diabetes: Systemic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Clinical Trials,” British Medical Journal, 343, 24 November, 2011.
  6. H. Shah, et al., “Genetic Predictors of Cardiovascular Mortality During Intensive Glycemic Control in Type 2 Diabetes,” Diabetes Care, 39 (11) 1915 (2016).
  7. J. Estenes, “Absence of Diabetic Retinopathy in a Patient who had Diabetes Mellitus for 69 Years and Inadequate Glycemic Control,” Diabetology and Metabolic Syndrome, 1 (13) (October 5, 2009)
  8. G. Gill, et al., “Insulin Dependent Diabetes of over 50 Years Duration,” Partical Diabetes International, 10 (2) 60 (2005); cf. J. Sun, et al., “Protection from Retinopathy and Other Complications in Patients with Type 1 Diabetes of Extreme Duration,” Diabetes Care, 34 (4) 968 (2011).
  9. B. Conway, et al., “Is Glycemia or Insulin Dose the Stronger Risk Factor?” Diabetic Vascular Disease Resarch, 6 (4) 223 (2009).
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Today I intentionally ate high carb because my new meds have me in the 70s and having not been there in years it is not fun.

A sort of type 2 correction.

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Sigh. I’m so tired of this circular debate.

Without even addressing the particulars of the study’s methodology and whether its conclusions may be trusted—because that has been done to death here and elsewhere and surely will be again, ad infinitum—ACCORD focused on cardiovascular outcomes. It was not interested in neurologic outcomes, renal outcomes, opthalmologic outcomes, etc., etc., etc. It’s a micro view of a macro issue. If some people have worse outcomes while many have better outcomes, that is on balance good from where I sit.

Is that actually the case, or is it not? Nobody knows. People draw general conclusions from this pinpoint of data (which it is, in the grand scheme) and there is nothing to tell whether those conclusions are true and good, or false and misleading. Nobody knows . . . but that’s the point.

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Well, there’s a lot of confirmation of the Accord’s basic point, as I indicated above, so it can’t just be discounted, as some have suggested above. Also, with respect to Accord’s having looked at only cardiovascular outcomes, consider the huge review of studies cited above which was done by B. Hemmingsen, et al., “Intensive Glycaemic Control for Patients with Type 2 Diabetes: Systemic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Clinical Trials,” British Medical Journal, 343, 14 November, 2011, which concluded that “Insufficient evidence exists to support the conclusion that intensive glycaemic control prevents the occurrence of microvascular disease assessed on a composite outcome, retinopathy, or nephropathy [in type 2 diabetics].”

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I’d love to get my A1C in the range you spoke of. I’ve taken oral meds for about 12 years - I was diagnosed T2 in ‘05…
6 months ago I started needing insulin along with my metformin, My endow now believes my diabetes resembles the LADA.
I’m curious - how do you only eat 25-30 carbs per day? I could see possibly doing that if I weren’t doing insulin…
#relearning

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I hope you (and @Judith_in_Portland) don’t mind if I jump in here. In general, the quantity of carbs consumed corresponds to the quantity of insulin needed to metabolize it. Other factors are also in play, such as insulin sensitivity, so if you want to reduce your daily carbs down to a lower level, like 25-30 grams of carbs per day, you will also need to reduce the amount of insulin you take.

That’s the general situation and things do vary from person to person and even within the same person by time of day. The amount of insulin required per gram of carb consumed is something best arrived at by personal experimentation. I’ve found limiting carbs to be one of the most potent tactics I use to manage blood glucose levels.

Taking insulin should not interfere with a choice to eat fewer carbs. Taking a fixed amount of insulin and then eating the amount to carbs to balance your blood sugar into your desired range is often referred to as “feeding your insulin.” In my opinion, this is backwards. It’s better to decide how many carbs you want to eat and then calculate a personal matching insulin dose. This is best done in consultation with your doctor, of course.

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Thanks, David, for taking it on. My oh my, we have been around this block a few times over the years, haven’t we!

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As I say: “If you want to treat diabetes ‘by the book’, you need to write a new book for every diabetic!”

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