The People's Perspective on Medicine

How Should You Treat Type 2 Diabetes? Doctors Disagree!

It often comes as a surprise to patients to learn that doctors disagree about how to treat type 2 diabetes. The internists are challenging the endocrinologists. It's intense!
Blood glucose monitor, diabetes,

The prestigious American College of Physicians (ACP) has challenged the American Diabetes Association (ADA) when it comes to how to treat type 2 diabetes. It’s the internists against the endocrinologists. The result of this conflict is likely to be confusion for patients.

What’s All the Fuss About?

The ACP is the largest medical specialty group in the U.S. It is comprised of over 150,000 internists, internal medicine subspecialists, residents, fellows and medical students. The organization issued new guidelines about how to treat type 2 diabetes (Annals of Internal Medicine, March 6, 2018). The bottom line is that the experts for the ACP are encouraging their colleagues to treat type 2 diabetes less aggressively than before.

The president of the ACP, Dr. Jack Ende, summarized the evidence-based guidance statement this way:

“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. The evidence shows 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.”

Heresy Among Specialists:

You might not think the difference between a goal of 7 to 8 percent vs. a goal of less than 7 percent would be such a big deal. Au contraire. This represents a huge fight between specialists. The ADA recommends getting AIC levels below 7 percent (Diabetes Care, Jan. 2018). The experts for the ADA go on to suggest that:

“Providers might reasonably suggest more stringent A1C goals (such as less than 6.5 percent) for selected patients…”

The difference between 6.5 to 7 percent and 7 to 8 percent may not seem like much to you. But it is the difference between aggressive blood sugar control and a more relaxed approach to the way doctors treat type 2 diabetes.

What is A1C?

Doctors abbreviate Hemoglobin A1c to HbA1c. Then they shorten it even more to A1C. This blood test, also referred to as glycosylated or glycated hemoglobin, is a measure of average blood sugar control over three months. Many health professionals prefer this metric to daily blood sugar readings. That’s because it gives them a rough idea how their patients are controlling blood glucose over a longer period of time.

Why Are Endocrinologists So Upset?

It’s all about the more aggressive vs. less aggressive way to treat type 2 diabetes. Intensive control of blood sugar has been a goal of the ADA for years. Many endocrinologists believe that this approach will lead to fewer complications of diabetes. We can imagine that there are patients for whom this approach would be desirable. But an aggressive approach to treat type 2 diabetes can have unexpected consequences for some people.

The feud between the internists and the endocrinologists centers around interpretation of research results. One of the biggest and best trials of the effects of intensive treatment (AIC levels of less than 6 percent) compared to standard therapy (targets of 7.0 to 7.9 percent) produced controversial results. The ACCORD trial upset the apple cart (New England Journal of Medicine, June 12, 2008).

The group of who were randomized to treat their type 2 diabetes aggressively had a:

“22% increase in all-cause mortality, a 35% increase in cardiovascular related death, and a 3-fold increase in risk for severe hypoglycemia. More intensive treatment also resulted in increased weight gain of more than 10 kg (27.8% vs. 14.1%) and increased fluid retention.”

You can learn more about the ACCORD trial in this article:

New Research Poses Diabetes Dilemma

The Risks of Hypoglycemia:

When patients don’t treat type 2 diabetes adequately they become vulnerable to many serious complications including eye damage, peripheral neuropathy and cardiovascular disease. Overly aggressive treatment, though, can put them at risk for dangerously low blood sugar (hypoglycemia).

Historically, this is usually considered a risk for people with type 1 diabetes who have to take insulin. A new perspective published in the Journal of Clinical Endocrinology & Metabolism (March. 5, 2018) suggests that it can also be a problem for people with type 2 diabetes.

Symptoms of Hypoglycemia:

When blood sugar levels drop too low, the patient may become shaky, spacey and experience sweating, headache and blurred vision. If allowed to continue, hypoglycemia can lead to fainting, seizures or coma. This can become an emergency, requiring hospitalization. Worst case, hypoglycemia can lead to death.

The authors call for personalized patient management strategies that will help all people with diabetes avoid the dangers of hypoglycemia. That is also the recommendation from the experts at the American College of Physicians. These internists are concerned about the complications of hypoglycemia. They too call for a personalized approach to treat type 2 diabetes.

What Should Patients Do When Doctors Fight?

We have written an article about this very question. Click on the link below to get The People’s Pharmacy perspective.

The Balancing Act:

We have always loved the revised story of Goldilocks and the Three Bears. That’s because it is a wonderful tale about moderation. Goldilocks rejected the first bowl of porridge because it was too hot. She rejected the second bowl because it was too cold. When she tasted the last bowl she said:

“Ahhh, this porridge is just right”

We think the way to treat type 2 diabetes requires a careful balance so the outcome is just right…or as close as we can get to that goal. That means aiming to prevent the serious consequences of diabetes while simultaneously avoiding adverse drug reactions and dangerously low blood sugar levels. Exercise and thoughtful eating can help.

We have also written a Guide to Managing Diabetes that provides some practical tips. Here is a link.

Share your own story about how you successfully treat type 2 diabetes below in the comment section. If you have ever experienced side effects from diabetes drugs we would like to know about them. What about hypoglycemia? Has that ever been a problem. Share your story so others can benefit.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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After being on insulin for 4 yrs A1c 6.5 and having severe lows in the teens. I switched to low carb/ high fat way of eating and hit the gym 3x a week. I lost 70 lbs and in 3 months time I came off of insulin..No more lows A1c for the last 2 yrs has been 5.6. I did this at age 71 if I listened to my Dr I would still be on Insulin

A year ago my A1c was around 13 and I was on Metformin which tore up my stomach so I stopped it. I was injecting 10 times a day with 3 diff insulins, but despite using oral and injectable meds my A1c could never get lower than 9.0.

Approx 6 months ago I began using a wireless insulin pump. Since then my A1c has fluctuated between 6.2 and 7.0. I have on occasion over dosed myself at bedtime causing my glucose level to drop into the 40’s and 50’s.

This condition only lasts a short time due to my eating a banana or some other sugar supplement. The system I use is from Omni Pod. My A1c has been consistently low and my real struggle is losing weight which I know can illuminate the disease from my body. I hope this helps someone out there.

I found a way of eating that reversed my Type 2. I did not know it could be done. I was not told by my doctor or anyone involved with the ADA. I am no longer on medication and do not have to worry about highs or lows. I feel great. Most of my information came from the book “Wheat Belly” by Dr. Davis and Social Media. Complete elimination is easier that limiting. I know others can do this if they were given the information.

Diet and,exercise have reduced,my numbers from 8 to 6.6. I have lost 55 pounds, but could still lose more. I am still obese. When I take meds, i feel awful ….. very dizzy and,weak.

My theory about blood sugar is to exercise eat the less sugary foods, vegetables and fruits, take supplements that will offset the sugar such as bitter melon and cinnamon etcetera, etcetera, etcetera. I’m an A1C 7 and not losing any sleep over it. I don’t take the recommended 500mg metformin three times a day. I’m doing fine with my balanced food intake. The only drug I like to take is the liprinosil 5 mg that helps my blood pressure. Am 75 years old and a little overweight but, again, I’m not losing any sleep over it. I function well.

Several years ago my A1C was 7.1. Doc said I needed to get it below 7 and called the pharmacy to give me prescription for Metfomin. I never OKed the med. so did not go get it when the pharmacy said it was ready.

I decided the war would be won by me alone. I started exercising again. I eliminated white foods(especially sugar). I lost weight and brought my A1C level down to 6.5.

Anybody can do it. By the way, I was not ever an overweight person. I was just eating too many sweets and not getting enough exercise. I will always have to watch it apparently. Through the years past I ate too many sweets so I have run low on natural insulin. Exercise actually helps your pancreas create more insulin.

I can’t see that Metformin has done anything for my Diabetes 2, except make me gain weight that I absolutely cannot lose.

I’m a Lipitor Diabetic! My blood sugars were 99 to 110 before my doctor put me on statins. Three months after starting Lipitor My blood sugars were up to 240. I asked my doctor if it could be the Lipitor. He said No. I asked Him how much Lipitor raises blood sugar. He said he didn’t know. I asked for an appointment with an Endocrinologist. My doctor said No, and My HMO said No. I Found an Endocrinologist of my own and, for a fee he gave me the facts about my medications and how much they would raise my blood sugars. He would not tell me if I should take massive amounts of Insulin or stop taking the medications. That’s my dilemma!

I spent most of my 30s, 40s, and 50s developing DM2. At 170 #s I was dx with it and began the standard treatment. My A1C came down to 6.8 but hypoglycemia and weight continued to be problimatic. Now, after 5yrs of low carb my weight is 130# no medication my A1C is consistantly 4.8 to 5.2. Best of all no hypoglycemia ever even if I don’t eat, my glucose has dropped into to the 80s and has not created any notable symptoms.

I think that the information that diabetes 2 is a disease that can be cured by dietary changes,exercise, and weight loss is probably true. So many of the people I know who are diabetic ( and that number is rising ) appear to believe that there is nothing they can do to deal with the disease beyond medication. I have just one diabetic friend who has finally begun to cut back on portions, change the food he eats, lose weight, and read about his disease and how he can at least control it better if not cure it.

My A1c was 13. I went on a low carb high fat diet. Within a week my fasting blood sugar was below 120, and two hours after breakfast it was below 100. My doctor took me off my oral medication and my blood sugar is averaging between 140 and 150. I am not eating so low carb that I am keto. I have about 60 net carbs a day. I am so happy to be off medication. And no worries about low blood sugar.

Higher or lower is all very interesting, but nobody (as far as I’ve found) talks about the accuracy of the little glossmeters we all use. The question is, how wide a variance from day to day should we tolerate before we conclude our blood sugar is either too high or too low? Of course this assumes that our behavior — what we eat, how much we exercise, etc., is consistent. I’ve found that the changes in my glossmeter readings do not seem to correlate with my behavior. Is this an artifact of my meter’s variance? How much do I attribute to it? 10 points? 15 points?

My husband has diabetes ll. He takes metformin. And he goes back and forth with Glipizide because twice when he took it then didn’t have a chance to eat he got dizzy and couldn’t see. So it’s better to not take it if you are reducing your calorie intake.
His A1C is 7.2. But has been 6.5.
He always checks his blood sugar before bedtime. It’s not good to go to sleep with it too low.

My doctor is in the camp of less aggressive treatment. She said studies have shown that by treating aggressively heart problems actually worsen.

I was treating mine very aggressively. My A1C was 5.4. As I have aged, and after living with the disease for over thirty years it became harder to control.

We moved, and that’s when I began going to a different doctor. She put me on insulin, but told me to try to keep my A1C at about 7. It’s 6.5.

Today doctors say one thing, tomorrow it will be something else. Do they know? I think they just are guessing and going along with what Big Pharma tells them.

My husband had type II diabetes. They put him on metformin but the side effects are that it actually raises the blood sugar, raises uric acid, etc. I discovered that his ph (urine) was acidic. He changed that, and the result went from 5.5 to 7.4. No diabetes.

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