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Why Do 65% 0f Type-2 Diabetics Continue to Die from CVD?

Question:
65% is incrediably high. Since some type-2s die from lows or car accidents caused by lows and some type-2s control their diabetes with a heart healthy life style, this number says worlds about the effectiveness of the medications treating type-2 diabetes. Treating type-2 diabetes is about preventing complications since few die directly from diabetes. I can think of many reasons this number is so high and I will address one. What do you think is the cause and what should be done.

Recently I have seen in a number of places, that insulin resistance is an independent risk factor for CVD. That means even if you get your glucose levels down, you still may be at high risk for CVD death. Insulin resistance being a major risk factor for CVD raises several interesting questions:

1. Why isn't a larger focus on cardio level aerobic exercise or weight training pushed for type-2 diabetics. I have seen many recommendation that diabetics should only do moderate level exercise.

2. Why isn't the class of drugs that treats insulin resistance, TZDs, the first line of treatment for type-2 diabetics after all it treats a risk factor for the number one killer of type-2 diabetics.

3. Why isn't insulin resistance screened for much earlier because many with insulin resistance have it years before their pancreas starts losing the insulin production battle. This would suggest that many diabetics are in line for a CVD death before ever being diagnosed with diabetes.

What do you think about CVD deaths in type-2 diabetics; causes and cures?

Chuck
Answers:
I think it has become accepted as gospel that most patients won't exercise, no matter what their doctors say to them on the subject. Therefore, that option isn't really on the table. You can mention exercise, as something which patients should do in addition to the real treatment they're getting (and we all know that real treatment comes from the pharmacy). But everyone understands that, when you mention exercise, you're just going through the motions. It's a ritual gesture. If you really meant it, you'd emphasize it, not mention it in passing after you had put down your prescription pad.

The thing is, the studies that call diabetes medications "effective" are defining effectiveness in terms of making the numbers on a lab report look better. A more important criterion would be reducing the chances that the patient will have a heart attack and die; a few studies have looked into that one, and the results have been pretty disappointing. It seems that drugs alone are not enough to improve cardiovascular health. The exercise part of the treatment isn't an optional add-on; it's required. But most people (and perhaps most doctors) think that, if your lab report is looking better, the drug you're taking is "working", and the problem is already solved.

I think it's still unclear why insulin resistance is an independent risk factor for heart disease. It may be that IR makes people produce excess insulin to compensate for it (excess insulin is known to have an inflammatory effect on the arteries). But some people with Type 2 have lost a lot of their insulin-producing capacity, so they can't really be blasting their arteries with too much insulin -- if IR is still a cardiac risk factor in that case, there must be something else about IR that's bad for the heart. I've heard different theories about what that "something else" is. If we understood this better, we'd be be in a better position to figure out what to do about it. But I doubt it will turn out that the right thing to do is to take pills and not exercise.
Answers:
One reason why people don't exercise is depression. It affects so many people that I know; especially T2s. Especially if you don't work for one reason or another or you are retired. And the medications for depression do not always help all the way. It takes a combination of cognitive therapy and medication to get oneself going, however, many people don't seek mental health help and/or have the insurance to pay for cognitive therapy.

Also, trying to begin exercise when you are fat and out of shape can be very scary. If its been a really long time since you've exercised, sometimes you are lucky if you can make it around the block without pain or breathlessness. And your back may be weak from laying around. A person might get up and try to start exercising and find so much pain that they give up.

All the stretching in the world will not help if your back is weak. See this video for back strengthening exercises:
Answers:
compassionateheart,

You are certainly correct about why some type-2s don't exercise although exercise is one of the best way to combat depression.

I think there are additional reasons that diabetics fail to exercise and a big one is what Tom stated, that it is not stressed enough by doctors. They will tell you if you don't quite smoking, lose weight or keep your glucose levels in control that bad things that will happen. They don't explain that without fitness, your life will be shortened just like smoking or that the quality of life will be much poorer! They will ask if you are taking your medication or to see your glucose log, but never how much exercise you have done in the last week or what your percent body fat is.

A person with insulin resistance is sort like an untuned car. There muscles aren't getting the glucose they need to function properly. Beside having to change life style, the ability to exercise is very difficult, important but difficult! The problem of exercising with insulin resistance is made much better with TZDs because that lowers insulin quickly and allows one to begin an exercise program easier and do harder exercise. It is like a tune up pill. The combination of exercise and TZDs have worked far better for me than either alone.

The last point I will make is that most diabetics, particular older ones, have physical problems that can give them an excuse not to exercise. My wife can always find reasons not to go to the gym. Some overdue the first time, ache, and decide exercisde is not worth it. It takes a strong will to exercise as part of one's life style just like keeping weight off, but it is just as important. One has to find creative ways to exercise as one ages and one is limited in what they do. Weight lifting helps lower glucose for me and one can target the muscles/joints that work.

If diabetics don't include exercise in their treatment, their rate of CVD will remain high; that is my thought.

Chuck
Answers:
Allow me to play Devils' Advocate here. I don't believe one needs to be a world class athlete to effectively treat diabetes, and I don't really believe insulin resistance is an independent risk factor for CVD.

Certainly physical movement is good for everyone, whether diabetic or not, it's the way we evolved. Don't take the nearest parking space to work or a store, and walk a little. Don't take the elevator, walk up the stairs, etc. Dance, walk, bike, kayak, do whatever you enjoy that allows you to get off your rearend, and move.

Most people who are insulin resistant, have high blood sugars, and high blood insulin levels, and these raise CVD risk levels. My low carb, ketogenic diet, actually raises insulin resistance, and I believe it's a nonfactor. The reason is simple, both my blood sugar and my blood insulin levels are low. I also practice intermittent fasting, and often bike, walk, or kayak in a fasting state. There is no problem with energy, versus those who I participate with, who've enjoyed a hearty breakfast, whether carbocentric or not.

From my perspective, there is not only more unknown with regards to diabetes than is known, we are regressing in our knowledge. Ever since George McGovern's Senate Committee on Nutrition (I believe in 1972), we've been involved in a disastrous war on fat, which has backfired. Americans have cut their fat intake with low fat or no fat foods, which replace the fats with harmful refined carbohydrates {and only a few years ago, with deadly trans-fats). It's hard for me to find full-fat foods in the supermarket. Yet I'm normal weighted, surrounded by obese people buying low fat foods. Doesn't make sense to me.
Answers:
Because less than 1% of type 2 diabetics are pro-active about treatment of their condition. The vast majority take the pills and/or insulin the doctor prescribes and make few, if any, changes to their lifestyle.

Only a minority actually follow that advice to see a dietician. Of those, the majority are told to follow a "heart-healthy" - but diabetic-disastrous - low-fat high-carb diet.

Only a microscopic minority are pro-active to the point of seeking out information beyond that given by their doctor or diteician or CDE.

And an even smaller minority are here reading this. Last time I checked there were less than 100,000 subscibers to here - in all its forms including the Community and the Forum. Even if you added in all the major forums you would be unlikely to reach 250,000. That is only one percent of the diagnosed diabetics in the USA.
Answers:


I'm here, Alan, and I appreciate your posts from Australia. I do think medicine is catching on about low carb for diabetes in the U.S., at least. There are groups on Facebook for diabetes, but it doesn't seem to be a good forum for getting education. This site was not on my Nutritionist's list of websites to go to. I'm going to print some posts out and give it to her. Just spread the word, as you can. The people here have helped me sooo much and I've even continued getting help from Valerie through Facebook, whom I "met" here. So, one at a time, we will do it.
Answers:
Ms. Janis Roszler,

May I know if you, as a Registered Dietitian and Certified Diabetes Educator, have advised your type 2 diabetic patients to eat heart-healthy low-fat high-carb diet? If you have, are your patients doing well on it? Or have they on their own decided to adopt high-fat low-carb diet instead?

I am asking because going 19 years since my diagnosis as a type 2 in July 1991, I have been eating the so-called heart-healthy carbohydrates in unlimited quantities and so far so good. In my last family doctor's, dentist's, and eye doctor's visits early this year, all results were perfectly well - kidney, heart, liver, eyes, dental, psa, A1c, cholesterol, blood pressure. All my past A1c's were 5.2% to 6.3%. The only pharma drug I have been taking is for my blood pressure.

Our family physician who diagnosed me in 1991 immediately referred me to a very smart lady registered dietitian. One of the many important things that I learned from her then which will stay with me all my life is the free foods. Since then, I have been eating more and more of these free foods with excellent results.

I will greatly appreciate your comments.

Thanks in advance.

Bonny
Answers:
Bonny,

you know perfectly well, that Janis will answer in the affirmative. She advocates a vegan diet. As to your 'heart healthy carbohydrates', I disagree that there is such a thing.

No one has yet commenced a long term study contrasting your low fat, high carb approach to my low carb, high fat diet. There have been some short term studies that suggest that low carb diets can be more effective. But long term, who knows.

The biggest problem I see with a higher carb diet, is firstly, most people cannot achieve the kind of blood sugars I target ({that is, under 90 all day long) and secondly, the blood insulin levels are likely to be higher as well, and this is an independent risk factor for CVD.

But there are many more complex interactions. So, my feeling, is that if someone is doing well with whatever regimen they are following, great, stick with it. If someone is not doing well with their regimen, I'd sure be looking to make some changes. Why keep doing the same things, and expecting different results?
Answers:

Nomorecarbs,

To me, you are a very intelligent person. I will never question anything you say because I am not smart enough to think that I know better than you.

You are so intelligent that since I have met you on this forum, I have always read and reread everything you have been saying. And I like everything you have been saying because you have been unknowingly, unintentionally and clearly answering for me the questions I would like to ask about type 2 diabetes, its proper and effective control, and your personal feelings on them. You do not miss covering all the the angles that can possibly come up on a discussion.

I have said this before and I will say it again: I do not trust Dr. Bernstein's approach to type 2 diabetes because he is a type 1 diabetic.

At this stage of the game, I strongly believe that nobody knows what type 2 diabetes is, how to treat it the right way, and how people get it. Each of us type 2s is expected to find the best solution to his own problems caused by his diabetes. We can listen to others' success stories and try to copy them but unfortunately one's success does not surely, automatically, and easily become another person's success.

God in His infinite wisdom created all of us to be different from one another in everything we humans can ever imagine.

Bonny
Diabetes Mellitus Type
Diabetes Nursing

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