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Should Type 2 Diabetics Give Up on Achieving a Healthy A1c?

According to Dr. Jack Ende, president of the American College of Physicians, regarding reducing hemoglobin A1c in those with type 2 diabetes: “ACP’s analysis of the evidence behind existing guidelines found that treatment with drugs to targets of 7 percent or less compared to targets of about 8 percent did not reduce deaths or macrovascular complications such as heart attack or stroke but did result in substantial harms.”

With this in mind, the ACP just released a statement declaring “that for most people with type 2 diabetes, achieving an A1C between 7 percent and 8 percent will best balance long-term benefits with harms such as low blood sugar, medication burden, and costs.”

Take a close look at the selection in bold in the first paragraph above: treatment with drugs.  It’s been shown time and again that forcing A1c lower with drugs not only does not reduce mortality or vascular complications, but it actually results in increased harm.  So what gives here?  Should patients with T2D give up trying to achieve healthy blood glucose levels and be satisfied with an A1c between 7 and 8?  Considering the harmful impacts of chronic, long-term hyperglycemia on eye health, kidney function, nerve function, and more—not to mention the increased risk for dementia conferred by higher blood glucose, this seems like a dangerous precedent.

An A1c between 7 and 8 represents an average blood glucose of 154-183 mg/dL.  While many type 2 diabetics certainly run far higher glucose, and A1c of 7-8 would no doubt be an improvement for some of them, why stop there?  Why not encourage them to achieve truly normal levels?  Just because drugs fail to lower blood glucose without triggering increased complications and mortality doesn’t mean there isn’t some way to accomplish this.

Since diabetes is diagnosed solely through measurements of blood glucose—fasting glucose, HbA1c, or response to an oral glucose tolerance test—then it makes sense to encourage interventions that lower blood glucose.  (Never mind the fact that type 2 diabetes may actually be driven first by high insulin, even in those whose glucose is still normal.)  One of the simplest methods—not to mention one that’s non-invasive—is a low carb diet.  In fact, this seems like the most fundamental, most obvious strategy: eliminate the dietary elements that raise glucose the most.  In most people, these are, of course, carbohydrates—specifically, refined carbohydrates; but some individuals are sensitive even to more wholesome carbohydrate sources, such as potatoes, beans, fruit, and other sweet or starchy vegetables.  Carbohydrate restriction is so effective, in fact, that some researchers have said it should be the default treatment for T2D.

To his credit, Dr. Ende did say, “Although ACP’s guidance statement focuses on drug therapy to control blood sugar, a lower treatment target is appropriate if it can be achieved with diet and lifestyle modifications such as exercise, dietary changes, and weight loss.”

Good thing studies are showing exactly that!

In a study in which overweight adults with T2D followed a very low carb diet and received counseling from dietitians, “the majority of participants (234/262, 89.3%) were taking at least one diabetes medication at baseline. By 10 weeks, 133/234 (56.8%) individuals had one or more diabetes medications reduced or eliminated.”  Medications eliminated included insulin.

In this study, baseline mean A1c was 7.6%, with only 52/262 participants (~20%) having an A1c of <6.5%.  At follow-up, 125/262—almost 48%—of participants achieved an A1c of <6.5%.  The kicker here is, among these 125 individuals, this reduced A1c—a level which moved these individuals from a diagnosis of full-blown type-2 diabetes to “pre-diabetes”—was achieved while taking only metformin (n=86) or, in 39 individuals, no diabetes medications at all.  Pre-diabetes isn’t exactly something to celebrate, but it’s all about context: if the classification comes because someone formerly fell into the category of full-blown type 2, but their glucose levels have dropped substantially, then this is definitely an improvement.  And keep in mind that these remarkable changes occurred in just 10 weeks—less than three months’ time.

A more recent study by the same group had similar findings: adherence to a low-carb diet is extremely effective for improving T2D.  Compared to one year of the usual care, a one-year program of very low dietary carbohydrate intake and continuous supervision by a health coach and doctor resulted in remarkable reductions in A1c, body weight, and medication use.  After a year on the program, a cohort of 262 overweight adults with T2D who had self-selected to participate in the low carb intervention saw mean A1c drop from 7.6 to 6.3% and also lost an average of about 12% of their body weight.  Even more impressive: “94% of patients who were prescribed insulin reduced or stopped their insulin use, and sulfonylureas were eliminated in all patients.”  And it wasn’t just glucose control that improved in the low carb arm.  HOMA-IR decreased by ~55%, hsCRP decreased ~39%, triglycerides decreased, and HDL increased, all indicating improvements in cardiovascular health.

This is stunning in its own right, but it’s even more impressive when compared to results for participants in the usual care cohort: they had no changes to HbA1c, weight or diabetes medication use.  So: usual care, continued reliance on medication, and no improvement in glucose control; or a low carb diet, coaching support, and major improvements in health?  This is a no-brainer.

It’s not only possible to dramatically improve A1c without radical pharmaceutical interventions that come with their own complications and harms, but doing so can actually facilitate reduction in existing medication usage, and in some cases, complete elimination of medication.

According to the ACP, “Lowering blood glucose may decrease risk for complications, but lowering strategies come with harms, patient burden, and costs.”  When accomplished via diet and lifestyle changes, though, there’s less patient burden and cost: less spending on medication, less burden of insulin injections, less tailoring one’s day around medication schedules and managing hypoglycemic events.

Some people might argue that adopting a low-carb, whole foods diet might increase someone’s grocery bill, but first, compared to insulin and oral diabetes drugs that do relatively little to improve the disease process anyway, spending a bit more on groceries seems like a fair tradeoff; and second, eating low-carb real food doesn’t have to cost more.  In fact, eating nutrient-dense, real, low-carb foods might even cost less, because there’s no spending on processed foods, which look cheap based on the price per box or bag, but which actually cost a king’s ransom when you look at the unit cost—the price per ounce or pound for refined corn, soy, and wheat embalmed with sugar and vegetable oils for infinite shelf life.

Not everyone with type 2 diabetes will want to follow a low-carb diet, and other dietary strategies can be effective.  But this should at least be presented as an option.  Plenty of patients might be willing to ditch their morning bagel in favor of sausage and eggs if they knew this also meant ditching their insulin injections.

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