4th Thursday Update

June 25, 2015


On the bright side

A study of men with Type 2 diabetes found that they lived longer if they were taking PDE5 inhibitors (a class of drugs used to treat erectile dysfunction, including such popular potions as Viagra, Cialis, and Levitra) than if they were not. This finding was considered surprising, in that erectile dysfunction typically indicates endothelial dysfunction (problems in the tissues lining the blood vessels), so any guy who needs to take a PDE5 inhibitor is thought to be at a heightened risk of dying from cardiovascular disease. (Adding to the cardiovascular risk that already comes with being diabetic.) The increased survival of diabetic men taking the drugs could mean that PDE5 inhibitors can be good preventive medicine for heart disease.

Well, it could mean that. But if PDE5 inhibitors prevent cardiovascular disease somehow, scientists haven't yet figured out the mechanism. And there are competing explanations for the increased survival of men taking the drugs. One plausible explanation is that the men taking the drugs were having more sex, and were less depressed -- two factors which appear to make men live longer.

When scientists are considering factors that affect longevity, they don't always remember to include "enjoying life" among them, but sometimes they do.


"Diabetic heart" explained

Uncontrolled diabetes is known to be damaging to heart muscle, presumably become excess blood sugar has some kind of harmful effect there, but the mechanisms involved have not been very well understood.

New research from Johns Hopkins has not only clarified the cause of this problem, but has found a possible solution to it. (Like most solutions of this sort, it works in rats, but nobody yet knows if it would work in humans.)

Muscle contractions, and the electrical signaling which triggers them, are both driven chemically by calcium. Heart muscle in many diabetes patients respond poorly to calcium, and the result is that contractions of the heart muscle in these patients are weak or irregular. Seemingly excess blood sugar does something to block heart muscle cells from responding properly to calcium, and in the long run this degrades heart muscle cells. But what is going on exactly, and can anything be done about it?

The Johns Hopkins researchers zeroed in on a compound known by the lovely name "O-GlcNAc" (it's a byproduct generated by sugar in the blood) and a "handler" enzyme which escorts it around the muscle cells. It turns out that diabetes patients have more O-GlcNAc in their cells (because they have more sugar in their blood), and this compound inserts itself into the middle of a contractile structure within the muscle cell built of tiny bodies called "sarcomeres". The O-GlcNAc blocks the sarcomeres from "cross-bridging" and thus from contracting properly. One of the researchers compared the effect of the O-GlcNA within the muscle cells to injecting molasses into a Swiss watch.

But the researchers did more than observe what was screwing up the interior architecture of muscle cells. They thought of a way to reverse the effect. An enzyme known as OGA has the effect of breaking down O-GlcNA, and the researchers found that they could use this enzyme to get rid of O-GlcNA within heart muscle cells. They also found that, once this was done, the heart muscle cells regained their ability to respond properly to calcium and contract normally.

Therefore, a therapy which either adds OGA to your bloodstream, or causes your body to produce more OGA, could become a way to treat "diabetic heart".

Seemingly, controlling your blood sugar would also have the same effect, as there would be less O-GlcNA produced in the first place. (I'm just throwing that out there, because nobody else will.)


3rd Thursday Update

June 18, 2015


It's time once again for me to review recent Google searches that have referred people to this site, to see if I can give their implicit questions an explicit answer.

"not peeing enough means diabetes"

You couldn't have got it more backwards! Peeing too much means diabetes -- and rather literally, too.

Diabetes, from a Greek word meaning "to pass through", originally referred to any health problem which caused excessive urination. Once the term "diabetes mellitus" was coined, meaning chronic high blood sugar resulting in excessive urination, the word "diabetes" by itself came to be associated with high blood sugar, which was confusing. Most people hear the word diabetes and immediately think it means diabetes mellitus and it has to do with blood sugar. However, there are diseases (such as diabetes insipidus) in which excessive urination is caused not by high blood sugar but by some other problem in the brain or kidneys.

Because the significance of the word diabetes has changed enough to cause confusion, doctors discussing excessive urination as a symptom (independent of any specific cause for it) usually refer to it as polyuria, or occasionally as diuresis. I suppose a diabetic person might eventually reach a point of not peeing enough, but that would probably indicate another problem -- perhaps kidney failure.


"blood and sugar in urine can't urinate"

That's a pretty alarming combination of symptoms, which you need to take to a real doctor. Dr. Google can't give you enough help with a situation this serious and complex.


"diabetes insipidus worse after pregnancy"

I imagine a lot of things are worse after pregnancy -- back pain, bad movies, waiting in line at the DMV, you name it. But there actually can be a direct connection between diabetes insipidus and pregnancy.

Diabetes insipidus (excessive urination not associated with high blood sugar) is usually caused by the brain not producing enough of a regulatory hormone called vasopressin (or the kidneys not being sensitive enough to the vasopressin the brain produces). During pregnancy, women produce a substance called vasopressinase, which has the effect of breaking down vasopressin, and if they produce too much of this stuff, diabetes insipidus can develop during a pregnancy, and linger for a time after the pregnancy is over.

However, none of this has anything to do with diabetes in the more familiar sense of chronic high blood sugar.


"can letting your glucose drop too low make you feel bad for whole day"

Maybe it depends on what you mean by "too low". If you mean "low enough to make you feel weak and shaky and anxious", that's a standard-issue hypoglycemic episode, and the symptoms of it usually go away in a matter of minutes once you take in a little carbohydrate and bring your glucose level back into the normal range. That's been my experience, anyway.

Anybody, diabetic or not, can experience the occasional episode of this kind. But if you're talking about an episode of severe hypoglycemia, the kind of extreme low that involves you regaining consciousness in an emergency room, unable to recall the fistfight you tried to start with the paramedics because you thought they were zombies -- if that's the level of hypoglycemia you have in mind, then I imagine a low like that could involve a longer wait before you feel better. If it's not as severe as that, yet you nevertheless feel bad all day, my guess is that something else is wrong, which needs to be looked into.


"is 4.9 considered hypoglycemia"

If you mean blood glucose measured as 4.9 mmol/l, no, that's not hypoglycemia -- it's equivalent to 88 mg/dL, which is within the normal range, even for a fasting test.

However, the symptoms of hypoglycemia (weakness, trembling, nervousness, sudden hunger, and so on) are not necessarily triggered by blood sugar being abnormally low -- they are usually triggered by an unusually rapid drop in blood sugar. Getting your blood sugar under control as a diabetic, even if you do it without medication, can result in feelings of hypoglycemia because your blood sugar level now drops faster after a meal than it used to. At least in my experience, putting up with mild hypoglycemic episodes is just part of the process of getting readjusted to a normal glycemic range; after a while, the body gets used to being there.

While you're going through that phase, you need to learn not to overcorrect for such things: a teaspoon of sugar in a cup of coffee is probably enough of a cure; you don't have to eat a whole birthday cake, even if that's what your nervous system is advising you to do.


"my morning glucose is 10 percent higher than post prandial"

This happens to a lot of people. The "dawn effect", which causes your blood sugar to rise significantly shortly before you wake up, causes some people to have fasting tests that look worse than their post-prandial tests.

The prevailing theory about the dawn effect is that it's a case of the endocrine system over-compensating for a drop in blood sugar during the early-morning hours. After several hours have passed since dinner, and the digestive tract is contributing nothing to your blood sugar, it's only to be expected that your blood sugar would gradually decline if your body did nothing to hold it steady. Dealing with this issue is supposed to be the liver's responsibility: it has a supply of stored sugar, and it doles out a steady ration of the stuff while you sleep, to keep you from going into hypoglycemia. At the same time, the pancreas is supposed to dole out enough insulin to make sure the sugar released from the liver doesn't build up excessively in the blood.

The problem is that, if you have diabetes, this system tends to get out of balance. The liver releases a little too much sugar, and the pancreas doesn't release enough insulin to compensate for it (or the body doesn't respond well enough to the insulin for the compensation to work). The result is a surprisingly high test result in the morning.

Some people find that taking a light snack before bed prevents them from getting lows during the predawn hours, and therefore prevents them from getting a reactive high by the time they wake up. I'm not necessarily recommending this, as it doesn't work that way for me. But I know people who say their fasting tests are lower if they have a snack at bedtime than if they don't, so I'm passing along the idea for whatever it is worth. If you try it and it doesn't work for you, don't keep doing it! (The things other diabetes patients recommend to you are usually worth an experiment, but not worth continuing if the experiment fails in your case.)


"my a1c is 6.2 is that bad"

It's elevated, but not elevated enough to support a diabetes diagnosis (that would require you to hit 6.5). This situation is usually called "pre-diabetes", which doctors think of as meaning "in the process of becoming diabetic", and which patients think of as meaning "possibly at risk of becoming diabetic some time in the distant future". Unfortunately, the underlying metabolic syndrome which causes blood sugar to start climbing up toward diabetic levels can promote cardiovascular disease even if it isn't yet diagnosable as diabetes, so it's best to go to work on controlling the situation before it becomes a crisis.


"what would happen if you couldn't produce insulin"

Cool -- now I get to help people with their homework!

What would happen is that you would develop Type 1 diabetes. In fact, that is pretty much the definition of Type 1 diabetes (the pancreas stops making insulin because the beta cells in that organ are destroyed by an auto-immune disorder, in which the body attacks some of its own cells as if they were invading microbes). The result would be that your blood sugar would shoot up to a very high level, but the energy in all that blood sugar would mostly go to waste, because your muscle cells wouldn't be able to absorb it, and most of the sugar would be excreted rather than burned as energy or converted to body fat. You would probably lose weight rapidly because of all those wasted calories. Then, as proteins throughout your body became "glycated" (gummed up by sugar), the various health problems known as diabetes "complications" would gradually develop over time. Fortunately, once your doctor found out what was happening, you could begin taking insulin injections to correct the problem.


"if your blood glucose is 120 will your urine glucose be 120 also"

No, but for interesting reasons.

The kidney is an extremely sophisticated filtering system, which allows unwanted compounds in the blood (such as urea, a toxic nitrogen compound which is an unwanted byproduct of protein digestion) to pass into the urinary tract. The really sophisticated aspect of this process is that the kidneys are able to recognize certain compounds in the blood which should not be allowed to pass into the urine, and it returns them to the blood supply. Glucose (blood sugar) is one of those compounds.

A transporter protein called SGLT2 latches onto glucose molecules as they pass through microscopic tubules in the kidneys, and escorts them back into the bloodstream rather than allowing them to flow out into the urine. Under normal circumstances, the SGLT2 transporters operate so efficiently that they don't permit any glucose at all to pass into the urine.

However, if the blood becomes extremely sugary, the SGLT2 transporters will be overwhelmed, and some glucose will leak into the urine. The blood-sugar level at which this breakdown happens is called the "renal threshold", and it's usually around 160 mg/dl. If your blood sugar gets above the renal threshold, glucose will begin to show up in your urine. (And when this occurs, osmotic pressure -- a phenomenon I don't have time to explain here -- causes extra water to flow through the kidneys along with the glucose, which is why excessive urination begins to occur at this point.)

A new class of diabetes drugs known as SGLT2 inhibitors -- or gliflozins -- operate by suppressing the SGLT2 transporters, so that blood glucose leaks into the urine all the time -- not just when blood sugar gets above the renal threshold. There are downsides to this approach (for one thing, sweetening your urine increases your chances of having a urinary tract infection, and I hear those aren't a whole lot of fun), but there's a lot of commercial appeal to the idea of pissing your diabetes away. I expect these drugs to become popular as more of them win regulatory approval.


"if dried urine droplets become tacky is that an indication of any other possible problems"

It certainly could be an indication of problems with the state of your housekeeping. Leaving that issue aside, making things more sugary does tend to make them more sticky, but touch-testing a dried urine splash is not exactly a high-precision approach to chemical analysis. If you suspect your urine is more syrupy than it ought to be, a urine test strip would give you a much better idea of what's going on. So would a blood-glucose test strip.

The tackiness of dried urine is not the quality of evidence you need when you're looking into your health.


2nd Thursday Update

June 11, 2015


Hemoglobin A1c and Deflategate

Metaphor alert: I'm going to talk about some complicated aspects of hemoglobin A1c testing by comparing them to a football scandal.

If you're reading this outside the USA, I should begin by explaining the background of a sports news story which received an absurd level of press attention on these shores, and presumably was ignored elsewhere. On January 18, 2015, a football team, the New England Patriots, won a game against the Indianapolis Colts, and was then accused of having cheated by using insufficiently inflated footballs when playing on offense. (Under-inflated footballs are supposedly easier to grab -- which matters, because the game we Americans mysteriously call football is played more with the hands than with the feet.) The Colts, using footballs inflated to regulation pressure when they were on offense, were thus at a disadvantage. A scandal of unlikely proportions was unleashed ("Deflategate", people called it), an investigation was conducted, and the Patriots were judged guilty of cheating by the National Football League. Unexpectedly serious penalties were handed down, causing much outrage among those who thought the violation was minor and may not even have given the Patriots any actual advantage. Many pointed out that the Patriots won by a score of 45 to 7, which makes it exceedingly hard to believe that they would have lost if they had been forced to work with a more firmly-inflated ball.

You could take the attitude that cheating is cheating, regardless of how much or how little it altered the outcome of the game -- and maybe that is the right attitude to take, if you are in the business of setting sports penalties.

But if you're not setting sports penalties, if you're just following the game, or playing the game, and trying to understand it better, it's probably more useful to analyze the actual impact of the cheating. Does underinflating footballs, to the extent the Patriots did it, really confer an advantage? And how? And for whom? And how big a difference to does it make? Is the advantage large enough to turn a narrow loss to a narrow win? Is the advantage large enough to turn a narrow loss to a 38-point win?

We don't have much information about those issues, and that's unfortunate. When people have strong feelings and weak information on a subject, they tend to overstate its importance. Someone who believed the "Deflategate" scandal was a really big deal might get into the habit of assuming inflation pressure is a crucial factor in any game, and might also get into the habit of explaining every lost game by speculating that underinflation is the cause of the problem, when the real issue lies elsewhere.

I think a lot of people do something like that in the case of the hemoglobin A1c test: they have heard vague reports about the test being thrown off by this or that circumstance, and this plants in their minds the habit of treating all A1c results with suspicion. When they get an A1c result that they don't like, they tend to look for a way to dismiss the result as inaccurate. Probably it's a mistake. Something went wrong. They ate or drank the wrong thing the day before the test, or they have hay fever, or somebody didn't inflate the football properly. Anyway, the outcome of the test isn't valid. This is certainly a comforting thought, if the test result was unwelcome and they don't want to accept it... but are they kidding themselves?

I get a lot of questions about the hemoglobin A1c test possibly being thrown off by having an infection, or being under stress. I'm pretty sure most of the people who ask such questions just got a disturbing A1c test result, and are trying to talk themselves into the idea that the test result is wrong. Probably something else that's happening to them has distorted the measurement -- after all, they've heard this happens all the time. This always sounds like wishful thinking to me (especially when someone other than me is doing it). It even sounds a little ridiculous to me: yeah, right, with a little more air in the football you would have come out ahead!

Well, there are certain medical circumstances which can raise questions about the accuracy of an A1c test result. However, not every medical circumstance you can think of has an impact, and not everything that does have an impact is likely to be having a significant impact in your own case. We have to look at these things systematically. If you want to dismiss the A1c result as inaccurate, ask yourself what specific problem you think interfered with the test result, and then investigate that issue to see whether it really could have made a significant difference to the test result.

Hemoglobin A1c testing is a more complicated thing than most descriptions make it sound. I understand the need to explain the test in simple terms -- at first -- so that newcomers to the concept can get a good basic grasp of it. But if you leave people with a good basic grasp of it, and never tell them anything further about the more complicated issues involved, they tend to indulge in misguided guesswork about the parts that haven't been explained to them. That takes them down the path toward thinking their A1c test result doesn't count because they've been stressed out lately.

Of course, some people simplify their description of the A1c test so much that they're essentially lying about it from the start. It is not a "measurement of average blood sugar"; no explanation of A1c should start there. What it actually does measure takes a bit of explaining, however.

Hemoglobin is an important protein in red blood cells, and the common variety of it is hemoglobin A. Over time, hemoglobin tends to become "glycated" (that is, it tends to get sugar bonded to it). Glycated hemoglobin A is identified by the subtype A1c. Lab testing can distinguish between hemoglobin A and its subtype A1c. Therefore, the A1c test measures the quantity of both A and A1c, and the test result is the ratio of A1c to A -- in other words, it specifies what percentage of total hemoglobin A (that is, A + A1c) is represented by A1c alone. If the test result is 6.1%, then 6.1% of your total hemoglobin A is in the glycated A1c form.

The medical significance of this result is that it is an indicator of the rate at which the glycation reaction has been going on in your blood for the last 3 months (that's how long red blood cells live), which in turn is an indicator of how sugary your blood has been lately, on average. As blood becomes more sugary, the glycation rate goes up, and a higher percentage of hemoglobin is glycated. This is significant not only as an indirect marker of how well controlled your blood sugar has been, but also as a more direct marker of how much damage is being done to your system from the levels of blood sugar that have prevailed lately (glycation, of hemoglobin or of any other protein, is harmful to tissues all over the body, and creates those famous "complications" of the disease).

However, the test gives us only limited, specific information: how much hemoglobin A and hemoglobin A1c is in your red blood cells. This information is highly reliable in and of itself, but in order to find any health significance in the result, we have to interpret it -- and the interpretation rests on certain assumptions. If the assumptions are wrong, the interpretation is wrong. The result itself is not wrong -- if the test result is 8.2%, then 8.2% of your hemoglobin A really is in the glycated A1c form. However, the medical meaning of that result is only as correct as the assumptions on which our interpretation is based.

The A1c result is usually interpreted in light of these particular assumptions -- which are not valid in every case:

Let me take these assumptions one by one, to see what can invalidate them. Please remember that I'm not suggesting that the A1c result should simply be disregarded if any such issues arise -- I'm just presenting these as factors your doctor must consider in interpreting the A1c test result. They affect the result, but not necessarily to a huge degree. (And they often make the result appear unrealistically low, not unrealistically high.)

Abnormal age distribution of red blood cells

Red blood cells are constantly being created in your bone marrow; they live about three months and are then recycled by the spleen. Our interpretation of the A1c result as an indicator of recent average blood sugar rests on the assumption that the patient's red blood cells have a normal age distribution. In other words, the patient hasn't experienced blood loss or dialysis treatment recently; that would skew the blood cell population younger, and yield a lower A1c result. Also, the patient doesn't have a condition (such as certain kinds of anemia) which delays blood cell death; that would skew the blood cell population older, and yield a higher A1c result.

Non-endogenous red blood cells

For most of us, most of the time, all of our red blood cells are of the home-grown variety. However, receiving blood transfusions can flood your system with highly-glycated red blood cells (because donor blood is stored in a sugar solution), resulting in an elevated A1c result.

Chemically altered blood

Certain kinds of blood diseases, medical treatments, and drug habits can alter your hemoglobin chemically, so that some fraction of it is not included in the measurement of hemoglobin A. This throws off the ratio, usually resulting in an artificially high result. (An exception is sickle-cell anemia, which skews the result low rather than high.) However, you should not assume that you have such a condition, nor should you assume (if you know you have such a condition) that it renders the A1c result meaningless. Ask your doctor what kind of effect, and how large an effect, it is likely to have.

Non-standard hemoglobin types

In some people, a significant fraction of hemoglobin is not of type A. Types C, F, S, and others are also seen. Again, this throws off the ratio, usually resulting in an artificially high result. In certain ethnic populations, this is a common occurrence. For example, Afro-Caribbeans read 0.4% high on average. Again, you should not assume that a factor of this sort is present and is rendering your test results meaningless; ask your doctor how much of an effect, if any, such issues are likely to be having in your case.


Some of the factors which are often suspected of invalidating the A1c result can indeed have an impact on it -- but not in a misleading way.

The two factors usually mentioned to me as possible reasons to dismiss the test results as invalid (somebody didn't inflate the football properly!) are infections and stress. Well, in some situations, infections and stress can have an impact on A1c results, but the effect isn't a distortion of your blood-sugar level -- it's an accurate reflection of your blood-sugar level.

Both infections and stress produce an inflammatory response in the body... which tends to reduce insulin sensitivity... which tends to elevate blood sugar. In other words, if you've been dealing with a chronic infection, or chronic stress, your A1c test result might go up -- but if it does, the reason for it is that your average blood sugar went up. It doesn't make the result less accurate, it just makes the result less welcome.

I would be extremely skeptical if anyone told me the reason their A1c result was up this time is that, during the week before they took the test, they'd had the flu and had been served with divorce papers. That's not enough to cause a significant jump (or perhaps any measurable jump) in A1c. When you venture into that speculative territory, you might as well be claiming that a 45-to-7 loss could have been turned into a victory, with a little bit more air in the football.

Whether we like it or not, we have to be realistic about these things. Yes, there are a large number of factors which can distort the medical significance of an A1c test, and doctors need to take these factors into account when they interpret the test results. But we shouldn't use the mere existence of such factors as an excuse to discard any test results we don't like.

If you lost a game, think about the real reason you lost the game -- and it probably isn't that there wasn't enough air in the football.


1st Thursday Update

June 4, 2015

The green grass of April and early May is now history, and the California hills are returning to their usual light-brown color. It's sad to see the greenness go (we get to enjoy it for such a brief period every year), but I still like getting outdoors. At least the trees are still green -- they can't take that away from me!


Diabetes: the up side!

I am so used to seeing studies which say that diabetes increases your risk of some apparently unrelated health problem -- everything from coronary heart disease to frozen shoulder is said to be more common in people with diabetes. It's becoming a little monotonous, in addition to being depressing. Aren't there any health problems that diabetes patients are less likely to get?

Well, it looks as if there is one such problem! Amyotrophic lateral sclerosis (also known as ALS, Lou Gehrig's disease, Charcot disease, and motor neurone disease) is apparently less common in people with Type 2 diabetes.

Well, if diabetes is going to protect me against some disease, ALS is a pretty good disease to be protected against. ALS causes a progressive loss of muscular control, so severe that it can end up costing you the ability to swallow and breathe. Some people (such as Stephen Hawking) are able to live with it for years; others die in months. It's obviously a terribly dangerous condition, and we know so little about what's causing it that it's hard for scientists to work on finding potential treatments for it. (The "ice bucket challenge" videos on the internet in 2014 were designed to raise awareness of ALS -- and also to raise money for research on the condition.)

Well, it's nice to know that the risk of ALS is significantly lower in Type 2 diabetes patients (the bad news is that this only applies to Type 2; having Type 1 makes your ALS risk higher, not lower). I'll take my silver linings where I can find them.

I hope there is more research done on the connection -- or rather the disconnection -- between Type 2 and ALS. Learning why Type 2 is protective against ALS will probably help us better understand both diseases.


Glycemic control and coronary risk

The old joke about the surgeon announcing "It was a successful operation, but the patient died" illustrates a sad truth about medical care: success is sometimes measured by things that aren't related very closely to the well-being of the patient.

Diabetes care is a field in which success is especially likely to be measured in terms of something which sounds important but ultimately doesn't matter as much as you would think it would. A surprising number of articles which claim to be reporting good news about some aspect of diabetes care (because the patients showed improvement in an arbitrary metric) end up mentioning, in a rushed and clearly embarrassed aside, that the patients receiving this successful treatment didn't actually survive any better than those who didn't get it. The important "not dying" criterion tends to be de-emphasized, as if it were understood to be less important than patients think.

Articles reporting such findings have their own literary form, and its conventions are as regular as those of a limerick. It's in the last paragraph that you let slip the part about mortality not being reduced by the treatment, "successful" though it was. The earlier paragraphs accentuate the positive.

That is how I see the good news about "tight" diabetes control, as reported in the New England Journal of Medicine. Medscape summarized the findings as "Tight Glucose Control Cuts CV Events", and ScienceDaily's headline was "Years of good blood sugar control helps diabetic hearts, study finds". The NEJM headline was neutral ("Follow-up of Glycemic Control and Cardiovascular Outcomes in Type 2 Diabetes"). The study compared patients receiving "intensive glucose lowering" therapy as opposed to "standard therapy", and found that "Over a median follow-up of 9.8 years, the intensive-therapy group had a significantly lower risk of the primary outcome [i.e., cardiovascular events] than did the standard-therapy group". However, in the final paragraph, we find out that "no improvement was seen in the rate of overall survival".

So there it is again, that "not dying" thing, which does not appear to be among the benefits of the "intensive glucose lowering" therapy.

I hasten to add that this was a study comparing two approaches to drug therapy (that is, a lot of drugs versus a truckload of drugs); it was not a study of good glycemic control regardless of how it was achieved. The study was not looking at people like me, who maintain glycemic control by achieved by exercising a lot and limiting carbohydrate intake. Therefore, it doesn't necessarily have much to say about people like me. That people who took a truckload of drugs had fewer heart attacks (but didn't live any longer, because they died of something else) doesn't say to me that controlling blood sugar is useless in the long run. It says to me that there must be a better way to control blood sugar than taking a truckload of drugs.

If we define success as good lab numbers, or even as fewer heart attacks, without regard to whether or not the "not dying" goal is achieved, than we are setting ourselves up to become characters in a medical joke: "It was a successful therapy, but the patient died".

I think that it's when you put the "not dying" criterion front and center that approaches to diabetes management which are not drug-centered begin to look more attractive.


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