Failure of the Blood Glucose paradigm T2D 16

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The current treatment paradigm of type 2 diabetes is the blood glucose paradigm. Under this paradigm, most of the toxicity of T2D is done by the hyperglycemia. Therefore, it follows that lowering blood glucose will amerliorate the complications even though we are not directly treating the T2D itself (high insulin resistance). The ACCORD study was a test of this glucotoxicity paradigm, and unfortunately, a complete and abject failure. Patients were randomized to tight blood glucose control versus usual control, with the expectation that tight control would show tremendous benefits. Instead, the trial proved there were none.

The mainstream media is picking up the fact that our current drug therapies for type 2 diabetes don’t seem to be of much use to anybody. The Canadian Broadcasting Company, for example, headlined that ‘New Study questions type 2 diabetes treatment – No evidence glucose lowering drugs help ward off complications”. Exactly right. Drugs don’t cure a dietary disease. Type 2 diabetes is a disease of insulin resistance and hyperinsulinemia. So why focus on lowering blood glucose, which is only the symptom? Isn’t that useless? Yes. Yes it is. You need to lower insulin, not glucose, because the disease is about too much insulin.

The problem is one of perspective. As long as you believe that hyperglycaemia is the main cause of morbidity, you expect that lowering blood glucose to provide benefits. The ACCORD proved this glucotoxicity paradigm is incorrect. Instead, the high blood glucose results from insulin resistance. That is the disease. And insulin resistance is due to hyperinsulinemia.

Imagine it this way. Type 2 diabetes is essentially a disease of too much glucose in your body. Not just the blood, but the entire body. If you fill up the cells of your body with glucose, pretty soon, no more can be pushed into the cells, so glucose spills over into the blood. But the underlying problem is an overflow problem. Insulin resistance is an overflow of glucose.

Using more insulin to move the toxic glucose from the blood into the cell accomplishes nothing. This is exactly what the study showed. If you have too much glucose in the body, you can do two things – don’t put any more in, or burn it off. Simply moving the glucose around the body so you can’t see it is not useful. And that’s what all these medications do.

Interestingly, the ACCORD study was not the first failure of the blood glucose paradigm. The UKDPS study was also unable to significantly reduce cardiovascular events or prevent deaths with intensive blood glucose lowering in type 2 diabetes. This was not even the first time that treatment increased death rates. The Veterans Affairs Diabetes Feasibility Trial also found an increase in death rates in the intensive group, but it was not statistically significant because of the small trial size. The earlier University Group Diabetes Program had also compared an intensive versus standard group. It, too was unable to find any benefit to intensive treatment. One certain subgroup, suing tolbutamide (a sulfonylurea medication that increases insulin) did have a higher death rate, though.

It would also start a parade of failures including the ADVANCE, VADT, ORIGIN, TECOS, ELIXA and SAVOR studies. It was not a single study that failed. There were multiple failures all over the world.

The failure should have burned away the prevailing glucotoxiciy paradigm like Enola Gay’s kiss. Certainly, at very high blood sugars there is harm to the body. But at the moderate levels of blood sugar seen in controlled type 2 diabetes, there was no benefit to further lowering. If you lower the blood glucose with medications such as insulin, there is no benefit. So clearly, the damage to the body does not result from glucotoxicity alone. The problem is that insulin itself in high doses can be toxic.

All these trials used medications that don’t lower the insulin. Both insulin and sulphonylureas increase insulin levels. Metformin and DPP4 medications are neutral for insulin. TZDs like rosiglitazone do not increase insulin, but increase insulin action. If the problem is both insulin toxicity and glucotoxicity, then increasing insulin toxicity to reduce glucotoxicity is not a winning strategy. And all the studies were there to prove it.

By 2016, a meta-analysis of all studies proved conclusively the futility of the blood glucose paradigm. Whether you are looking at overall deaths, heart attacks, or strokes, tight blood glucose lowering had no benefits at all.

However, these failures were not enough to convince diabetic associations to embrace new treatment paradigms. They were set in their ‘glucose or bust’ mindset and nothing could change their minds. So they refused to change their treatment strategies despite proof that these were complete failures. Their strategy of ‘prescribe medication to lower blood glucose’ had no been proven to have no significant health benefits. So, reflecting upon this new information, they decided that the correct strategy is ‘prescribe medication to lower blood glucose’. O…M….G…

For example, the Canadian Diabetes Association in 2013 guidelines still continues to recommend a target A1C of 7%. Why? Haven’t we just proven that lowering A1C from 8.5% to 7% provides no benefit? Why would we give more medications for no benefit. Isn’t that totally stupid? Yes… Yes it is. But there you go. The CDA can’t very well say “We have no clue what you should do”, so they give guidelines that go directly AGAINST the available evidence. Kind of like a Bizarro world Evidence Based Medicine.

Then they write “Glycemic targets should be individualized”. If there should not be a target, then say so, dammit. This is precisely what this paper describes. There is no evidence for benefit of tight glcemic control, yet 95% of diabetic guidelines recommend target blood glucose and tight control. WTF??

 

This slide compares the effect of tight glucose control on the outcomes of most importance to clinical medicine – death, heart attacks, strokes and amputation. Virtually all studies show there is no benefit for any of these outcomes.

Statements published that recommend tight control have been slowly dropping since the ACCORD study. When study after study comes out to refute the hypothesis, you might suspect something is up. In 2006, most published statements still recommended tight control. By 2016, only 25% did. That is, the overwhelming majority of experts knew that tight blood glucose control was irrelevant. So, why do we still obsess over blood glucose numbers in T2D?

Unfortunately, it’s likely because diabetes specialists have not yet understood that this disease is about hyperinsulinemia, not hyperglycaemia. The drug companies, on the other hand, are all to happy to leave the status quo, which is extraordinarily profitable for them.

 

 

2017-10-14T21:48:35+00:00 49 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

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49 Comments on "Failure of the Blood Glucose paradigm T2D 16"

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KibbyRose
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So how can we measure insulin levels? What is the alternative to testing blood glucose numbers?

Sue
Guest

We tried to get an insulin test from our doctor, but he said it was a “waste of resources”. WOW. Had one done when we were 4 days into fasting, and my husband was at <1, which is what is to be expected under the circumstances. We have yet to get one done under normal eating routine.

http://www.diabetesselfmanagement.com/blog/do-you-know-your-insulin-level/

Ivor Cummins
Guest

Excellent Jason – very high glucose not good for body – but striving to lower some moderate levels with expensive drugs is stupid.

Fix both Insulin the Elephant (and glucose issues) by addressing root cause – LCHF, fasting and all the other sensible approaches… 🙂

Roger Bird
Guest

Sensible, but not profitable, except of course for the individual and society.

Jin
Guest
When I was taking insulin back in 2009 my weight started increasing at an alarming rate. I stopped taking it in august 2009 and all other diabetes meds. I still went to regular check ups over the next four years and most things appeared fine. After four years with no meds I started getting nerve pain in my feet. It was now 2013 and Dr Moseley’s 5/2 book had come out I also discovered the Diet Doctor. With this combo my nerve pain went away and I still haven’t touched any diabetes meds. I’m not advising anybody to do this,… Read more »
Roger Bird
Guest

I’m going to go out on a limb and advise people to do it. Or at least study it and consider it. (:->)

Kevin Mattson
Guest

I remember reading about the antiseptic revolution, and the cultural resistance by established surgeons, and other medical folks, to the mere inconvenience of washing hands between patients. With billions of (name your currency) at stake, in addition to professional reputations, licensing, and god knows how many other issues, will any weight of scientific osmotic pressure shift the paradigm? Waiting for the retirement or death of the old guard of medical societies is one thing, but will greed ever pass?

BernardP
Guest

Dr. Fung, I’m lost in the continuity.

This is T2D 16

I have T2D 13 dated June 9 2016, “A New Paradigm of Insulin Resistance.”

Since then, There have been other posts, but none that I can find with T2D 14 or T2D 15 reference.

Links to T2D 14 and T2D 15 would be appreciated. Thanks

Andrea
Guest

I did a search and found T2D 14 and 15 on this page:

https://intensivedietarymanagement.com/?s=T2D+14

BernardP
Guest

Thanks!
I had those posts saved in pdf, but at the time of their publication, they were not labelled as T2D 14 and 15.
The universe is again in balance…

Karen
Guest

Tight glucose control and A1c goals are not in themselves the problem. It’s the methods you use to achieve those that are the issue.

I can’t measure insulin at home but I can use a glucometer to make sure that the food I’m putting in my mouth isn’t going to provoke an out of whack insulin response.

sten bjorsell
Guest

Same here. And morning fasting glucose is very good to check and regulated with foods. Result: lots of fats, and vegetables, no processed foods and careful with proteins give good readings. When water fasting for 2-3 days blood glucose have been just over 3 for me and since energy then is way up over normal, the “hypoglycemia” is matched with ketones. After a while no measurements needed, but glucose meter is good to “tune in”.

BobM
Guest
Slight problem: protein causes an insulin response. An insulin response can be caused just by thinking about food (eg, right before eating it), by anything sweet such as gum (even if sweetened by non-nutritive sweeteners), etc. For me, I found intermittent fasting to be more beneficial than just eating low carb and eating many meals per day (as we’re told we have to eat). Even though I was eating low carb, eating too many meals caused an insulin response that was not beneficial for someone who was insulin resistant. At one time, I also tried to have “sweet” low carb… Read more »
Roger
Guest
Diagnosed prediabetic with hypothyroidism in January, I had gained 40 pounds in 2015. Started 16-18 hour daily fasting intervals 5-6 days a week in mid January but plateaued at 20 pounds lost in June. I discovered this blog a month ago, it took about a week to go through it all. Added a weekly 64 hour fast a few weeks ago and the pounds started dropping again and I feel great with more energy. Backed off to a 40 hour fast last week and it looks like that may be enough for now. If not I’ll look at adding a… Read more »
Roger Bird
Guest

Jason, “One certain subgroup, suing tolbutamide” should read ” One certain subgroup, using tolbutamide”

Roger Bird
Guest

Jason, you might want to recheck this sentence: “Their strategy of ‘prescribe medication to lower blood glucose’ had no been proven to have no significant health benefits.”

Roger Bird
Guest

Jason, “The drug companies, on the other hand, are all to happy” should read “The drug companies, on the other hand, are all too happy”

Roger Bird
Guest

The best way to discover the truth concerning health and health care is to experience health building (holistic health, alternative healing, complementary medicine, taking responsibility for one’s own health, whatever people want to call it) for one’s self, as people here with Dr. Fung are experiencing left and right. The more that they do experience real health building, the more that they will learn to disrespect the conventional medical authorities.

Dave
Guest

Let’s just stop eating sugar and flour and keep it simple to solve the problem. We do not need donuts to live!

Nick
Guest

Careful Dave…treading into scary water here.

Bryan
Guest

Dr Fung. I’ve always been curious about this. From your office to the Canadian Diabetes Association offices is what? Ten miles as the crow flies ?

Has anyone from the CDA ever called you up and said “Gee, Jason. Looks like you are doing some great things out there in Scarborough. Could you come over and meet with us so we can learn to help patients too? What can we do to help you, Dr Fung?”

Or is that a silly question?

Mike
Guest

I would guess that the majority of their funding comes from Pharma. The phrase “bite the hand that feeds you” comes to mind here.

As Dr. Fung has said earlier, there’s a lot of money at stake here, right down to individuals’ salaries.

Why change your tune when you can make lots of money by sticking to the story that every doctor was taught in medical school? Seems like a safe, profitable strategy.

Sandy
Guest

More likely they are meeting with their lawyers trying to figure out ways to shut him up…as is being done in Australia and South Africa…

Bob
Guest

So what’s the answer? All I see is a bunch of digital diarrhea.

Nick
Guest

If hyperglycemia is the symptom of too much insulin is it right to conclude then that hyperglycemia is natural response (read a feature of human development not a flaw a la John Durrant) intended to save the body from storing additional sugar where there is no room? I’m not T2 so I don’t know what the dangers are of not addressing the hyperglycemia. Is there greater damage done to the patient by cramming sugar into the body rather than letting it course through their blood? Doesn’t the excess sugar eventually get expelled naturally in the urine?

Jin
Guest

Hi Nick,
Whether it’s right or wrong I don’t know but those were my thoughts back in 2009. I also had some faith in the wisdom of the human body.

Xanthra
Guest

“Enola Gay kiss” you paint word pictures that are funny and stay with me. Wish we could measure our insulin resistance like we can our blood glucose. I can get my insulin level every 3 months but that may not be more meaningful that a frog hair to tell me what my insulin resistance is.

Ben Fury
Guest
All you need is fasting triglycerides and glucose to guesstimate insulin resistance fairly accurately. “A novel criterion for identifying metabolically obese but normal weight individuals using the product of triglycerides and glucose” SH Lee et al, 2015 “The TyG index is a simple marker that correlates well with the degree of insulin resistance measured by hyperinsulinemic-euglycemic clamp studies.” TyG index Method: Multiply fasting TG and BG. Divide by 2 Run Natural Log (ln) [NOT (log)] Men with values over 8.82 and women with values over 8.73 are most likely to be insulin resistant and have double the chance of developing… Read more »
Darren
Guest

Thank you sharing this paper, I have been looking for an insulin proxy and this one looks great !

Ben Fury
Guest

You’re welcome! I was unaware of it till I found it referenced on Dr. Georgia Ede’s excellent Diagnosis: Diet site.

Jim
Guest

Thanks for sharing. I have been reading the published reports available on the development of this proxy for insulin resistance. It looks good to me.

Bob
Guest

What does it mean to increase insulin action but not insulin?

Nate
Guest

Increasing insulin action actually means increasing your body’s sensitivity to it. Thus, the insulin’s activities are able to do more even though the dose of insulin has not been increased.

Wenchypoo
Guest

Go Jason!! Your book should be out soon…pre-ordered it and looking forward to it.

Eric
Guest

Measure fasting insulin?
Why?
Why not just use 3 of the Insulin lowering techniques?
16 8 intermittent fasting everyday
Low carb 30 grams or less
And .6 grams of protein per kilo of weight.

What else? Time!
Eric

Walt
Guest
Is that an over simplification? I am still having a problem with LC vs VLC. Doesn’t this issue rightfully need to differentiate simple carbs from complex, well, for one thing. Next I don’t use MFP to watchdog my calories in so much as distribution of calories. By default, as I recall, MFP sets daily carb, unspecified, to 50% of the daily calories. I dropped it to 30%, with protein at 20% and fat at 50% It shows that carb percentage as 113g. From the nutrition/Nutrients page I seem to avg 65g/day which is roughly half of the 113. Interpreting what… Read more »
Jin
Guest
Hello Walt, A few weeks back I did an experiment where I had 150 grams of white sugar only daily for a fortnight. I got similar results you would get from fasting or going very low calorie, lost weight, lowered blood sugar, lowered blood pressure etc. You may draw the conclusion that types of carbs matter less and amounts matter more? This site focuses on keeping insulin low and the arguments for that are very reasonable but if you eat a lot of fat aren’t you just delaying the clearance of sugar from your blood? Could it not be more… Read more »
Walt
Guest
Hi Jin, Here is the thrust of my issue with the focus by some on here for VLC. Getting to the heart of the matter, Dr Fung in OC, starting on pg 219 under “What to Eat”.. 1) Reduce your consumption of added sugars. (check!) 2) Reduce your consumption of refined grains (check!) note: this would be sugar and flour, right? In this section “Carbohydrates should be enjoyed in their natural, whole, unprocessed form…”. 3) Moderate your protein intake. (check!) 4) Increase your consumption of natural fats. (check!) I read that to mean nuts as well as meat. 5) Increase… Read more »
BobM
Guest
Dr. Fung believes the Atkins diet fails because people tend to regain some weight over time in tests of these types of diets. Unfortunately, the dieters increase their carb intake (e.g., to 130+ grams/day), which is no longer Atkins. Did the diet fail or the dieters? The Atkins diet never failed me. However, I was eating 5+ meals per day, each of which caused an insulin response. That’s when I started intermittent fasting to change the times when I eat food and protein. And that helped. Now, I’m combining a ketogenic diet (very low carb) with intermittent fasting. Overall, I’m… Read more »
JoMichelle
Guest
somebody help me…..every different MD, NP,PA….HAS DIFFERENT PLANS…none really work….my triglycerides have been ignored by all branches of medicine for 20 years. Minimum time on visits spent….Ignored Let next doctor deal with it….careful what you write down, scares 95% medical people. Take oral meds, insulin. Read about study at Birmingham Al. Had good response with cardiac med that releases another hormone from pancreas. Any updates on this or other studies? Really need someone to help me understand some of this on consistent basis. Not many people have time. Current doctor is new to practice, so far really great. Again time… Read more »
Stefan
Guest

What about T1? They should have low insulin level unless they have perfect A1c? (which most don’t have) so their average insulin level should be lower than people in general or normal (except occasionally when they are low) unless they are T2 also, and still they have higher ‘overall deaths, heart attacks, or strokes’.
So surely it is not as simple as you say, blood sugar does play a role.

Victor
Guest

Well, T1 diabetics have lots of insulin because they are taking it. That is the definition of type 1, they are “insulin dependent”. And by the time they are having their cardiac events they have been diabetic and on insulin for many years.

Stefan
Guest

But why would a type 1 take more insulin than a none diabetic produces, the definition of Type 1 is ‘cant produce insulin’, so they need to inject, so they need to inject the same amount that a none diabetic produces naturally, nothing more, unless they are type 2 also.

Nita Watkins
Guest

I stopped lantis and metformin…..I’ve been very faithful to lchf diet for about 8 weeks…..my glucose numbers are still running 200+ ……I have a dr apt in 11 days…..how long does it take to lower the readings? (I was taking 4 ….500 metforminER and about 20 units of Lantus twice a day)

Stefan
Guest
When eating LCHF you take in less glucose, now either your values goes down or you reduce your medication. If you are lucky you get to the state where you don’t need medication and have good glucose values, or if not you get to a better state (which you seams to have gotten to) where your insulin is reduced and you have same glucose. Now you can either increase insulin or metformin a bit (not as much as before) get both less mediciation and better values, or stay as you are. Hopefully the reduced insulin will make you loose weight,… Read more »
Nita Watkins
Guest

I haven’t gotten any replies…maybe I didn’t do it right?

Nick P
Guest
I’ve been on a LCHF diet for 3 years. intermittently fast on occasion and take 1000 mg of metformin a day. I’m trying to lower my BG levels, hence A1c. I realize the insulin level is the problem, not the BG. My reason is trying to increase my overall health, recover from coronary artery disease, reduce T2 pre-diabetes, maintain a healthy weight and keep energy levels high. I feel what I’m doing is working. My A1c is now 5.5, male 6’0″, 162 lbs, 67 yo, feeling good. Am I incorrectly assuming eating LC all the time, getting a lot of… Read more »
JohnM
Guest
Insulin levels are driven primarily by carbohydrates. Fasting drops blood sugar levels quite efficiently but you must work closely with your doctor to adjust your prescription(s). Exercise will decrease glycogen somewhat but it’s best use is for retaining muscle mass during weight loss. To understand why this is consider a carb-dependent marathon runner who “hits the wall” around mile 20. The roughly 100 calorie burn it takes to run one mile multiplied by 20 miles is 2,000 calories which happens to be the total average amount of muscle glycogen contained in the body. A carb-dependent runner has effectively “run out… Read more »
Dwayne R
Guest
I get your theory but I’m confused. ACCORD is a travesty of an example of tight glucose control since it used poly pharmacy to do so and didn’t address dietary or lifestyle. Secondly ACCORD’s figures and tables prove their reasoning wrong. More ANY cause deaths occurred in the higher a1c group than the lower, while more heart deaths occurred in the lower-could not have been a ‘byproduct’ of the method and medications used? Thirdly The Hisayama Heart Study in Japan strongly correlated heart incidence to a1c and found that as one’s a1c fell so did heart incidence. Fourth The process… Read more »
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