Does Type 2 Diabetes Always Get Worse?
The single most dangerous idea you are likely to encounter after getting a diabetes diagnosis is the belief that science has proven, beyond a doubt, that no matter what you do, your Type 2 Diabetes will get worse.
Your doctors probably believe this. Though they may give lip service to the idea that you can control your disease through diet, exercise, and drugs, most family doctors actually believe that nothing you can do will make much difference in your long-term outcome. This is why they are not likely to urge you to take an aggressive approach to managing your disease but merely write prescriptions for drugs that, if they do anything at all, do a mediocre job of controlling your blood sugars.
Why Doctors Believe this Toxic Myth
They've Seen Poor Outcomes Among Their Own Patients
Doctors will tell you that they've treated lots of patients with type 2 diabetes and that few, if any, of their patients can control their diabetes with diet. They'll say that their patients cannot lose weight, and that even with good control they end up with complications.
What they don't understand is that the diet they have been recommending, thanks to the American Diabetes Association's partnership with so many national and state health authorities, is a high carbohydrate, low fat diet that contains so much sugar and starch it would raise the blood sugar of most normal people. Bananas and whole wheat bread won't control diabetes, but a diet that lowers your intake of starches and sugars often will--no matter how much fat it contains.
They Think the UKPDS Study "Proved" People with Good Control Deteriorate
Doctors will also tell you that a large-scale study, the UKPDS (United Kingdom Prospective Diabetes Study) proved that even with good control patients with Type 2 diabetes inevitably deteriorated over time.
The UKPDS, they'll tell you, found that the A1c test results of patients with good control gradually worsened every year. Not only that, but many doctors also believe that UKPDS really showed that good control can only make a small difference in the rate of complications, and that as a result lots of people with good control still get complications.
That last bit isn't just me being paranoid. For many years you could read it in the words of Dr. Roy Taylor, a professor of medicine and metabolism at the University of Newcastle upon Tyne. His words appeared in a slide presentation he gave to other medical specialists. This talk was presented by the Annenberg Center for Health Sciences and published by Medscape December 22, 2003 as an online course offering good for earning one continuing medical education (CME) credit. Unfortunately the link to this has Now Expired.
In this presentation, Dr. Taylor pointed to a chart taken from UKPDS data titled "Newly Diagnosed Type 2 Diabetic Subjects Showing Progression of Retinopathy." He explained,
These data are usually presented as showing a wonderful difference between the groups, [those controlling their blood sugar and those not] 37% relative risk reduction. But take another look. This slope is unfortunate. This slope is almost equally unfortunate for the individuals concerned. Although intensive therapy in type 2 diabetes over 15 years makes a difference, it's not a staggering difference.
Later when he discussed the UKPDS findings about the progression of nerve damage he said "the abnormal nerve function continues to progress inexorably"
When discussing early signs of kidney damage, he delivered the same message. "Intensive therapy [i.e. blood sugar control] does not seem to be able to stop this."
So it was no surprise when this highly influential doctor concluded that controlling blood sugar in type 2 diabetes may make a small difference,
...but not such a huge difference that you would want to go out of your way as a patient to achieve it, perhaps, if you were shown this graph and told that over 15 years of intensive therapy you would be not much different compared with a "laissez faire" approach.
Abandon Hope All Ye Who Enter Here?
If Dr.Taylor was right, it would make sense to take a fatalistic attitude towards your diabetes. If a diagnosis of diabetes sentences you to a life haunted by nasty complications and premature death why put yourself through all the miseries of a life-long diet and the struggle to watch what you eat every day? If there is nothing you can do, it is rational behavior to shift your energy elsewhere and enjoy life--including the foods you love--while you can.
But it is not true, and those of us active in the online diabetes community who have been achieving normal and near normal blood sugars for those 15 years Dr. Taylor found so depressing are not experiencing the terrible complications he expected us to have. Dr. Taylor and his peers missed one extremely important point in considering the UKPDS data.
"Good Control" in UKPDS and Common Medical Practice is Really Mediocre Control
Though doctors were seeing patients with what they called "good control" go on to develop complications, and though the UKPDS did show that patients with what they defined as "good control" did deteriorate over time, "good control" in the UKPDS study, as is the case in most medical studies, was defined as having A1c test values near 7.0%.
At the time UKPDS was published the 7.0% A1c was believed to correspond to an average blood sugar of 172 mg/dl (9.6 mmol/L). (Recent CGMS studies suggest the average might be closer to 155 mg/dl or 8.5 mmol/L) Whatever the actual equivalence, this average blood sugar level is considerably higher than the level at which neuropathy begins, arteries start to stiffen, kidneys begin to clog, and beta cell damage occurs--which we have documented HERE is 140 mg/dl (7.8 mmol/L) after meals and, in some cases, an A1c rising over 6.0%..
UKPDS Participants were Probably Spiking Way Above 200 mg/dl (11 mmol/L)
Even more important, you must realize that to a 7.0% A1c test result reflects an average blood sugar sustained over the past several months. And because it is an average, it does not distinguish between the person whose average blood sugar level of 172 mg/dl was achieved by maintaining their blood sugar at a steady 172 mg/dl throughout the day and the person whose blood sugar surged up to 300 mg/dl after eating high carbohydrate meals and then plummeted to 70 mg/dl as insulin kicked in, insulin that was injected or stimulated by the sulfonylurea drugs that force the beta-cells to produce more insulin.
The participants in the UKPDS study were told to eat a low fat/high carbohydrate diet and were given metformin, insulin stimulating drugs, and insulin to counteract the very high post-meal blood sugar spikes this diet causes.
So it's likely that most UKPDS participants--and your doctors' patients who have been following the standard dietitians' advice to eat a high carbohydrate, low fat diet--the this is what happened: They spent hours each day after eating with their blood sugars somewhere between 200 and 300 mg/dl but these highs were balanced by d periods of insulin-stimulated low blood sugar.
Those who were given insulin and sulfonylurea drugs were told to eat high carbohydrate snacks to keep them from the very real possibility of experiencing dangerous and even fatal episodes of hypoglycemia, since it is impossible to control how much insulin insulin stimulating drugs will release and the doctors in the UKPDS were not matching insulin to the participants' carbohydrate intake. So the patients in the UKPDS probably did have blood sugar that was rollercoastering up and down all day, which is a pattern that does lead to serious diabetic complications.
UKPDS Really Proved that an A1c in the 7% range Is Toxic!
The UKPDS results show that patients eating high carbohydrate diets and using drug regimens that allow their blood sugars to rise high enough to produce glucotoxicity for many hours each day will continue to experience complications. These patients will also see their blood sugar control deteriorate over time as their remaining beta cells succumb to glucotoxicity.
Think of it this way: What would you think of the competence of a doctor who told you that most patients who quit smoking develop lung cancer--but defined "quit smoking" as "Smoked only 10 cigarettes a day?"
That's exactly the same thing going on here, because the blood sugar targets doctors are prescribing for their patients are way over the level where good research has proven that organs are irreparably damaged. (Details HERE.)
A Note about the New ADAG A1c Equivalents
The latest formula proposed to equate A1c results with average blood sugars lowers the equivalent average blood sugar for a 7% A1c to 155 mg/dl or 8.6 mmol/L. However, this is still higher than the 140 mg/dl (7.7 mmol/L) level at which damage occurs and, more significantly, since it is an average blood sugar, it continues to hide those very high post meal blood sugar spikes which damage your organs.
The A1c that Corresponds to Truly Normal Blood Sugar Levels
While your doctor might call a value near 7.0% "good control", the blood sugar level that corresponds to what truly normal people experience is near 5.0%. Using the latest formula for converting A1c to average blood sugar, that 5.0% A1c translates into an average blood sugar of 97 mg/dl or 5.4 mmol/L.
Another study, EPIC-Norfolk, found that the risk of death from heart attack for all people, not just those with diabetes, was half as much when A1c test results were below 5.0% than when they were above it. However, the risk of the other, classic diabetic complications--nerve damage, blindness, and kidney failure--remains very low as long as the A1c remains under 6.0%, which is the range most labs assign to "normal." That 6.0% A1c translates into an average blood sugar of 126 mg/dl or 7.0 mmol/L using the most recent, ADAG, formula.
Another Less-Known Study Has more Impressive Results then UKPDS
As we mentioned earlier, the A1c is only an average. It ignores the very important question of how high blood sugars are spiking after meals. So what happens if instead of measuring only the A1c, you measure post-meal blood sugars and attempt to control how high they go?
A ground-breaking Japanese study answers this question definitively. The researchers in this study, conducted in Kumamoto Japan, found that by using post-meal blood sugar targets, they were able to keep the A1cs of participants in their study stable over its entire 6 year course. Instead of the "inevitable decline" in blood sugar control we saw in the UKPDS, these people with type 2 diabetes saw no deterioration at all.
Not only that, but over the course of the study, the incidence of retinopathy, kidney damage, and nerve damage, were dramatically lower in the group that maintained tight control of their post-meal blood sugars. In fact, the intensive intervention group as a whole saw slight improvements in the qualities of their nerve damage by the end of the study rather than the deterioration seen in all other studies.
Long-Term Results of the Kumamoto Study on Optimal diabetes Control in Type 2 Diabetic Patients. Motoaki Shichiri, Hideki Kishikawa, Yasuo Ohkubo, Nakayasu Wake. Diabetes Care. Volume 23 Supplement 2, 2000.
What makes this study so interesting is that the average A1c test results of the people in the Kumamoto "intensive intervention group" was identical to the average A1c of the people in the UKPDS at the beginning of the study. What was different was that the blood sugar control strategy the Kumamoto study used focused on keeping post-meal blood sugars lower.
While the average blood sugar was the same for both groups, the Kumamoto group NEVER let their blood sugar hover at the high levels that the UKPDS study participants reached.
This is extremely good news for people who do not wish to succumb to inevitable decline. And, in fact, it is even better news than the foregoing would suggest, because the patients in the Kumamoto study were controlling their blood sugar using an intensive insulin regimen which required that they keep their blood sugars higher than normal to avoid the danger of severe low blood sugars. So the people in the "intensive intervention" group whose results were so impressive compared to the "intensive intervention" group in the UKPDS still had A1cs near 7.0% and post meal blood sugars that rose to 180 mg/dl after meals.
What this suggests is that using an even lower post-meal blood sugar target could further lower the incidence of complications. The subjects in the Kumamoto study, though they had significantly fewer complications, still developed some of classic diabetic complications. Since their blood sugar target--180 mg/dl (10 mmol/L) was well above the 140 mg/dl (7.7 mmol/L) level where complications begin, this could have been predicted.
The real value of this study is in showing that A1c is a poor measurement of control and that lowering post-meal blood sugars targets is far more effective in preventing complications regardless of A1c.
A 2006 Study Proves Not All Type 2s Deteriorate and Some Even Improve
A long-term study of people with Type 2 diabetes run at the Mayo Clinic measured the C-peptide levels of people with Type 2 diabetes every two years over a period of twelve years. Here's what they found:
Insulin secretion . . . declined with increasing duration of diabetes in approximately half of the patients but either increased or remained essentially constant over time in the other half.... These data indicate that although a decrease in insulin secretion over time is characteristic of type 2 diabetes mellitus, it is not inevitable.
What screams out of the page here is this: Why didn't they study the people whose insulin production didn't decline or improved and find out a bit more about them? Were they better controlled? Eating a certain diet? And was the rise in insulin due to increased insulin resistance or to decreased blood sugar stress. Without this information, the study is not as informative as it might be. But it certainly answers the question "Do I have to Deteriorate" with a resounding "No!"
Effects of Duration of Type 2 Diabetes Mellitus on Insulin Secretion.Farhad Zangeneh, et al. Endocr Pract. 2006;12:388-393. Full text available HERE
What if you Keep Post-Meal Blood Sugar Spikes Below 140 mg/dl?
Just keeping blood sugar from spiking over 180 mg/dl made a huge difference in the incidence of complications and even improved neuropathy. But we know that neuropathy starts when blood sugars spike over 140 mg/dl. So the question that is still unanswered by this study is this: what would happen to people with type 2 diabetes who were able to keep their blood sugars under 140 mg/dl--the level at which it is believed that serious damage begins?
Unfortunately, you won't find a study that answers this question because most doctors believe that it is impossible for people with type 2 diabetes to achieve that level of control.
And it is impossible if patients attempt it while eating a high carbohydrate diet. But plenty of people online who a follow a lower carbohydrate diet have found that they are able to prevent their post-meal blood sugars from rising over 140 mg/dl, without injecting any insulin.
The Key is the Strategy Known as "Eating to Your Meter"
The way that people with type 2 diabetes are able to reach truly good control is described here: How to Lower Your Blood Sugar
This strategy is simple. You use your blood sugar meter to test your blood after every meal and eliminate from your diet the foods that raise your blood sugar over 140 mg/dl at one hour and 120 mg/dl at 2 hours.
This strategy has worked for many people whose A1cs were as high as 13.0% at diagnosis who were able to bring them down to the 5% range within a few months. I've maintained an A1c in the 5% range for most of the past 18 years. I have developed none of the classic diabetic complications.
Some people can achieve this level of control with dietary control alone. Others find that it helps to take metformin. Some will need insulin. But most people with Type 2 diabetes can achieve it without extreme measures or starvation diets and many do.
Where are the Studies of Long-Term Consequences of Truly Good Control?
There are none. To date there is no study of people with type 2 diabetes who have consistently achieved post-meal blood sugar levels under 140 mg/dl. In fact, most studies besides the Kumamoto study have completely ignored the question of what post-meal values participants achieved.
Because we only have studies that show that patients who maintain blood sugars in the toxic range well above 140 mg/dl and who spike over 200 mg/dl daily inevitably deteriorate, it is premature to conclude that all patients with type 2 diabetes inevitably deteriorate.
Don't Settle for Mediocrity No Matter What Your Doctor Advises
Doctors have indeed seen thousands of patients with Ttype 2 Diabetes fail to lose weight--because they put them on low fat/high carbohydrate diets that don't work for people with diabetes. They've seen them develop complications with good control, only because "good control" meant spiking over 200 mg/dl after every high carbohydrate meal.
Studies of "low carb diets" and diabetes have come up with disappointing results, but the reason for this is that ithe diets prescribed in these studies were the highly restrictive ketogenic diets which other studies have shown very few people, whether they have diabetes or not, can stick to. People who eat ketogenic diets for a while and then end up crashing off them do not see dramatic improvements in their health. ut many people active in the online diabetes community who restrict carbohydrates without eating extreme ketogenic diets have been able to stick to their diets for years and even decades. They have done very well. So have those who combine moderate carbohydrate restriction with with the few safe diabetes drugs that are available.
What do you Have to Lose?
If you pursue a lowered carbohydrate, "Eat to your Meter", regimen and keep your blood sugars under 140 mg/dl at all times, and a decade hence studies show that even with excellent control and normal blood sugar levels patients still deteriorate, all that you'll have lost is a lot of carbohydrate-laden meals (and possibly some weight.) But if you settle for that 7.0% A1c control your doctor recommends, with its post-meal spikes over 200 mg/dl, and in 10 years the studies show that keeping blood sugar under 140 mg/dl at all times prevents most diabetic complications, you may have paid for your choice with bleeding retinas, failing kidneys, and gangrenous toes.
I decided to go with that 140 mg/dl target back in 1998, when I was diagnosed with blood sugars that were spiking into the mid-200 mg/dl range after eating any carbs. I added safe drugs, metformin, insulin, and later repaglinide, because that let me eat enough carbs to be able to keep hitting my targets as the years went by without feeling utterly deprived. That approach has worked out well for me and I highly recommend it. But the approach you choose is up to you. Just remember, it's not your doctor's retina, kidneys, and toes that are at risk here.