Diabetes: Controlling Blood Sugar Is Not Enough

I’m sure all of you who live with diabetes or know someone who carries the burden of the disease will find their diabetes management has been inadequate.

This is because nearly all diabetics are fixated on keeping their blood sugar under control. As long as glucose levels are within acceptable limits, they feel the disease is under control.

Nothing can be farther from the truth. In fact, you may be deluding yourself that all is good even as your heart, kidneys, eyes etc are just rotting away, as it were.

In fact, my good friend Dr Shiv Harsh MD, a heart specialist, says he considers diabetes to be basically a heart disease.

To get this blog going, I’m paraphrasing a great article from New York Times that I came across a few years ago. It is made a difference to my diabetes management.

Most people discover they have Type 2 diabetes by accident, mostly after a routine urine test. The test reveals your blood sugar level is sky high and glucose is spilling into your urine.

“You’ve got diabetes,” confirms your doctor.

So, from then on, like most others with diabetes, you become fixated on your blood sugar. Your doctor has warned you to control it or the consequences could be dire – you could end up blind or lose a leg. Your kidneys could fail.

You try hard. When dieting does not work, you begin counting carbohydrates, taking pills to lower your blood sugar and pricking your finger several times a day to measure your sugar levels. When they remained high, you agree to add insulin to your already complicated regimen. Blood sugar is always on your mind.

But in focusing entirely on blood sugar, you end up neglecting the most important treatment for saving lives — lowering the cholesterol level. That protects against heart disease, which eventually kills nearly everyone with diabetes.

Like I said in the beginning, Dr Shiv Harsh considers diabetes a heart disease. (I’m putting this in layman’s language; Dr Shiv Harsh has a more nuanced approach. I’ll get him to write on this blog sometime.)

Moreover, most diabetics also miss a second treatment that protects diabetes patients from heart attacks – controlling blood pressure. Most assume everything is taken care of if you can just lower your blood sugar level.

Blood sugar control is important in diabetes, specialists say. It can help prevent dreaded complications like blindness, amputations and kidney failure.

But controlling blood sugar is not enough.

Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. What is going on? We can only conclude that people are not aware of their risks and what could be done about them.

In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by GPs (family doctors) who have had just a few hours of instruction on diabetes, while they were in medical school. Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

In part it is the fault of proliferating advertisements for diabetes drugs that emphasize blood sugar control, which is difficult and expensive and has not been proven to save lives.

And in part it is the fault of public health campaigns that give the impression that diabetes is a matter of an out-of-control diet and sedentary lifestyle and the most important way to deal with it is to lose weight.

Most diabetes patients try hard but are unable to control their disease in this way, and most of the time it progresses as years go by, no matter what patients do.

Ninety per cent of diabetes patients have Type 2 diabetes, the form that usually arises in adulthood when the insulin-secreting cells of the pancreas cannot keep up with the body’s demand for the hormone. The other form of diabetes, Type 1, is far less common and usually arises in childhood or adolescence when insulin-secreting pancreas cells die.

And, like many diabetes patients, you end up paying the price for your misconceptions about diabetes.

Most diabetics think the biggest risk from diabetes is blindness or amputations. You never think about heart disease and have no idea how important it is to control cholesterol levels and blood pressure mostly because doctors do not advise you to take a cholesterol-lowering or blood pressure drug. And you do not think you need them.

Indeed, most people with diabetes are unaware of the danger that heart disease poses for them.

A survey by the American Diabetes Association found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.

Yet, when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.

So, if you are one of those who don’t think you are at increased risk, finding out that you are and that you can decrease that risk substantially could literally change your life.

The science is clear on the huge benefits for people with diabetes of lowering cholesterol and controlling blood pressure.

With cholesterol, levels of LDL cholesterol, the form that increases heart disease risk, should be below 100 milligrams per deciliter and, if possible, 70 to 80. Yet, diabetes patients with LDL cholesterol levels of 100 to 139 often are told that their levels — ideal for a healthy person without diabetes — are terrific.

But many practicing doctors just don’t know that an LDL cholesterol number that is normal for someone without diabetes is not normal for someone with diabetes.

Not surprisingly, most diabetics do not know the other measures proven to prevent complications in diabetes.

Sure, high blood sugar is dangerous. It can damage the small blood vessels in the eyes, leading to blindness; the nerves in the feet, leading to amputations; and the kidneys, leading to kidney failure. But no matter how carefully patients try to control their blood sugar, they can never get it perfect — no drugs can substitute for the body’s normal sugar regulation.

So while controlling blood sugar can be important, other measures also are needed to prevent blindness, amputations, kidney failure and stroke. But, alas, most diabetics are doing none of them.

The common assumption that Type 2 diabetes is simply a consequence of being fat. And that losing weight will help cure it.

Obesity does increase the risk of developing diabetes, but the disease involves more than being obese. Only 5 percent to 10 percent of obese people have diabetes, and many with diabetes are not obese.

To a large extent, Type 2 diabetes is genetically determined — if one identical twin has it, the other has an 80 per cent chance of having it too. In many cases, weight loss can help, but most who lose weight are not cured of the disease. You can lose 20 kg but still have diabetes.

So if you’re diabetic worried only about blood sugar levels, get ready for a new diabetes regimen: a statin to drive your cholesterol level very low, drugs to lower your blood pressure, besides insulin and drugs to reduce his blood sugar levels.

Remember, you’ll never be out of the woods. You’ve got to face that.

And it is not just that many diabetes patients are overweight, as people with Type 1 diabetes, who often are thin, also have a high risk of heart disease. There is something about diabetes itself, researchers say, that leads to high levels of LDL cholesterol and a form of LDL cholesterol particles that is particularly dangerous. Diabetes also leads to increased levels of triglycerides, which are fats in the blood that increase heart disease risk, and in diabetes is linked to high blood pressure.

Being obese or overweight, in contrast, are supposed to be “weak contributors to heart attack risk.”

Type 2 diabetes does not exist in isolation. Underlying diabetes are all these cardiovascular risk factors.

It has taken quite a while for the alarm bells to go off because it is heart disease researchers, not diabetes researchers, who have conducted the seminal studies.

The key to saving lives is to reduce levels of LDL cholesterol to below 100 and also control other risk factors like blood pressure and smoking. The cholesterol reduction alone can reduce the very high risk of heart attacks and death from cardiovascular disease in people with diabetes by 30 per cent to 40 per cent. And clinical trials have found that LDL levels of 70 to 80 are even better for people with diabetes who already have overt heart disease.

Studies of blood sugar control have been more problematic than those of cholesterol lowering.

In Type 2 diabetes, the most ambitious effort was a huge study in Britain. It found that rigorous blood sugar control could lower the risk of complications that involved damage to small blood vessels, a list that includes blindness, nerve damage and kidney damage. But there was no effect on the overall death rate. There was a small decrease in the number of heart attacks but it was not statistically significant, meaning it could have occurred by chance.

Since researchers are still groping in the dark, as it were, cholesterol lowering, for patients with Type 1 and Type 2 diabetes, is the most effective and easiest way by far to reduce the risk of heart disease and the only treatment proven to save lives. But doctors say achieving the recommended cholesterol levels usually means taking a statin.

Some patients resist, wary of intense drug company marketing to patients and afraid of side effects like muscle or liver damage which, although extremely rare, have frightened many away from the drugs.

Yet lowering cholesterol with statins is much simpler than anything else diabetes patients are asked to do. And the drugs are among the best studied and the safest on the market.

My own doctor says if he had to rate the different regimens for a typical middle-age person with Type 2 diabetes, the first priority would be to take a statin and lower the LDL cholesterol level. (I take one statin after dinner.)
Besides, two other measures to protect against heart disease, blood pressure control and taking an aspirin to prevent blood clots, should not be neglected.

Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.

But even when you do take the right steps to control diabetes, the grueling process can simply wear you down.

In fact, a fistful of prescriptions, including a statin, blood pressure medications and one for the drug that most diabetics dread – insulin – besides regular checks for eye, nerve and kidney damage and watching what you eat and count carbohydrates is enough to drive anyone crazy.

Diabetes specialists say they are well aware of how daunting the program can be. Many go to the doctor once or twice and walk away saying, “I don’t want to do this.”
Meanwhile, no matter what they do, most people with Type 2 diabetes get worse as the years go by. Patients make less and less insulin and their cells become less and less able to use the insulin they do produce.

That is why it is not uncommon to start initially with diet therapy, then after a few years you need to add a drug that improves insulin sensitivity. Then when that drug isn’t enough, the doctor adds a second drug that improves insulin sensitivity by a different mechanism. Then he add a drug that stimulates that pancreas to make more insulin.”

Then patients with Type 2 diabetes may need insulin itself, but when that happens they have to take even more than a person with Type 1 diabetes — two or even three times as much — because their cells no longer respond adequately to the hormone.

Nevertheless, while it is not easy to re-energize burned-out patients, at the very least doctors and patients should know what is important.

We already have the miracle pills – statins and blood pressure medications – that are cheap but what is imperative is patient education and physician training that this stuff is out there and this is what doctors should be focusing on to make a difference in lives.

Note: I am NOT an expert. I am managing diabetes with moderate success and want to share published material appearing elsewhere. DO NOT start any medication without consulting your doctor. Get your lipid profile (12 hours fasting before test) and BP checked before you meet your doctor next.

If you have anything to share with other diabetics, do post your experiences on this blog

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Comments

  • Aralı Kayarola Takımı  On May 8, 2011 at 5:29 pm

    I was suggested this web site by my cousin. I am not sure whether this post is written by him as no one else know such detailed about my difficulty. You’re wonderful! Thanks!

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