The timing was perfect as it could not have happened at a more opportune time. Two articles in JAMA made claim to the fact that our treatment of diabetic patients with typical diabetic medicines increases the risk of MI and CVD. What? I thought that we needed tighter BS control to lower the risk of CVD and diabetic vascular disease? Later, the NEJM published a study that tight BS control did not improve CVD outcomes and even showed an increase in CVD events. What, how can that be? Is everything that I/we have been teaching, preaching and doing for the last 30 years incorrect? Now, after reading Jason Fung’s book I understand why that is. It is true that the higher the HgBA1C level, the worse the prognosis and the sooner one dies from the foregoing diseases. However, just because high levels of HgBA1C are associated with increased morbidity and mortality, that does not mean that lowering the HgBA1C results in less disease, or that lowering the blood sugar is of benefit. It makes sense to lower BS and gain tighter control and lower HgBA1C levels if high levels increase the risk of disease, but the outcomes prove otherwise. Why? Maybe because what we have been doing, and falsely misled to believe, is wrong. Lowering blood glucose is correct and appropriate, however, how we lower it is the key to understanding why using one method improves but the other worsens outcomes.
A recent TV ad for a GLP-1 analog claimed that there was no increase in MI or CVD events with this medication; their selling point was that there was no increased risk of MI? Yay, yippee, finally a drug that does not increase heart attacks! Wait. What? Why are we giving drugs to lower BS that in turn increase heart attacks, cause significant weight gain, and increase morbidity and mortality? I thought that lowering BS was good. For years I kept increasing diabetes meds, trying to maintain tighter BS control. But the patients all gained weight and their disease got worse. So, I added more meds and started long-acting insulin and they gained even more weight. I once bet a patient that if he lost 20 pounds I would give him $10,000. He failed. Then I went double or nothing. Not only did he fail but he gained weight. I blamed him but little did I know and realize that it was my fault and not his. This was before I read Jason Fung’s book The Diabetes Code and learned how and why DM meds made CV disease worse. My heart sank.
A recent video on Medscape made reference to the fact that “Cardio-Metabolic Disease” should be made a new specialty. Based on all the GLP-1 analogs and sodium-glucose cotransporter 2 inhibitors reducing weight, disease, and MI risks, the specialty is definitely changing and gaining momentum. So why are these new drugs any different? Although these meds work by various mechanisms to lower BS, lower HgBA1C levels, and improve CVD outcomes, the main importance is that they lower BS by different mechanisms other than increasing beta cell function, insulin levels, and driving glucose into the cell. These new wonder drugs decrease appetite, slow down glucose absorption, decrease gluconeogenesis, and increase glycosuria through the kidneys. The most important take away is the ability to decrease BS by different mechanisms other than driving glucose into the cell which all past drugs did, particularly insulin. By cramming all the excess glucose into the cell, the cell becomes overloaded with glucose which the cell must dispose of by storing it as fat and glycogen or converting it into triglycerides. Hence, the onset of fatty liver, fatty pancreas, fatty kidneys, dyslipidemia, NAFLD and NASH. I blamed all my patients for their weight gain and disease progression. And I blamed myself for not being more vigilant in maintaining tighter BS control. I had no clue. Mea culpa, mea culpa, mea maxima culpa.
In June, Reaven published in the NEJM that intensive glucose control in type 2 DM patients proved just as likely to cause a MI as standard therapy. Patients also gained weight and had worse disease outcomes. Perfect. There was no better outcome in MI, CVA, CHF, CVD, death, DM complications, or QOL scores. Even after 15 years of tight control, no benefit. So, what was their suggestion to improving outcomes? The researchers recommend treating DM even sooner and much more aggressively, as though 15 years of tight BS control was not enough? (Einstein said insanity is doing the same thing over and over again but expecting different results!) Professor Simmons stated that the data from the VADT study was consistent with findings from other studies. She finally admits that perhaps we should decrease medications if the risks outweigh the benefits. The authors do note that these results are before the GLP-1 receptor agonists and SGLT2 inhibitors were available. However, their treatment suggestion was to use more and more drugs that consistently do not work. Hmmm. Those thousands of researchers need to read and grasp Jason’s book in order to see why they, and their patients, fail.
In the REWIND study, dulaglutide reduced MI risk by 12%. That’s relative risk and not absolute risk which was much smaller. (The RR was 12% but the absolute risk (AR) was only 1.4%, with 3.4% MI in control group and 2.0% in treatment group=1.4% AR). It was the first major study that proved superiority over standard care, which has been consistently harmful. (An absolute risk reduction of 1.4% is quite underwhelming, but the researchers jumped for joy). So, there is less harm with the new drugs than in comparison to standard therapy (which increased risk), but what about with control groups? “In assessing the individual components of the composite outcome, Gerstein noted that there was no discernable effect observed for nonfatal MI with dulaglutide and a neutral effect observed for CV death.” You mean, no benefit? That is correct, no benefit. No benefit after spending millions of dollars on drugs and they do not work to reduce CVD? Hmmm. Their conclusion was that dulaglutide “could be considered for the management of glycemic control.” Could be? Why didn’t they state, “should be or must be?” Because the results were underwhelming and the cost $900/month!
There are better, safer, tried and true solutions to the above. That is what Part V Hormones and Beyond is all about. Jason Fung will review his secrets and insight for success. I will review all the medical literature demonstrating what we should be doing as well as what we should not be doing. Hope to see you in October.