New tools, particularly more effective weight-loss medications coming to market, should allow diabetes patients more control over their weight, Gabbay said.
The American Diabetes Association, in line with the American College of Cardiology, have created new guidelines which include a lower target for blood pressure of less than 130 over 80. For LDL cholesterol, (the bad kind,) the new guideline calls for a measurement of 70 for people without heart disease (down from 100) and 55 instead of 70 for those with established heart disease.
Losing 15% of body weight, as opposed to the previously recommended 5% should yield more health benefits. The guidelines also call for more aggressive treatment to prevent the progression of chronic kidney disease. "Diabetes continues to be the leading cause of end-stage renal disease.
The new guidelines call for more careful screening for foot ulcers and peripheral arterial disease, both of which can lead to amputations.
Many people with diabetes are prone to sleep apnea, a potentially dangerous condition in which someone stops breathing briefly during sleep. The treatment of diabetes, particularly with weight loss, can improve sleep apnea and improving sleep apnea can help control diabetes
Timely post, JeffâŚsort of. Coinciding as it does with my monthly annoying check in with the chronic care management coordinator at my PCPs (actually their computer software program) asking me redundant questions on the assumption that my hypercholesterolemia is secondary to metabolic syndrome/T2D/diabesity.
As far as a more personalized approach to medical care (because weâre all inviduals) even those newly revised lipid guidelines are still on the high side for some. After the initial assault on my âslightly elevatedâ LDL-C with Lipitor, it dropped a bit to 80âŚwhich my PCP was very pleased with. Intervention cardiologist thought it was still âhorribleâ and introduced me to Repatha. After just the first shot, it was down to 33âŚwith a target of <25. Me, Iâm very thankful for BigPharma right now and the potential for saving me from BigCoffin (or worse)
Such a hoot. First full workup visit with cardiologistâŚthis was after my CAC scan and subsequent CT angio (with contrast and HeartFlow analysis) âŚhusband was telling him how he "doesnât know anyone fitter than me. Me and cardiologist looked at each other and said âjust like Jim Fixxâ.
My wifeâs adopting the use of Repatha (in conjunction with Ezetimibe) allowed her to drop taking six Colesevalum horse-pills a day and get to what was a decent number. Based on questioning her doc yesterday, she is now back on all three to get to the new benchmark.
That said, the use of Repatha was, indeed, a game changer (as she continues to avoid statins).
Unfortunately I was only able to give you one rec.
Two fold problem.
1)people are lazy without discipline. They want to eat krap and want simple solutions to fix self inflicted resulting disease.
2)medicine is a business. They put product that adds to the bottom line. Medical journals are now filled with articles written by pharmaceutical industry paid researchers to push product.
It might surprise you to learn that when blood pressure lowering drugs were first introduced to the market and prescribed to patients, there was little evidence that they actually helped the patients live longer.
A problem is that in 90% of cases, no specific cause can ever be identified.
Another coupla of medical that does not extend life are coronary by pass surgery & carotid endarterectomy. An added bonus of the carotid endarterectomy procedure is that 7% of those patients that under go the surgery have a stroke or die.
Dr Norton Hadler on coronary by pass procedure.
The first would be interventional cardiology and cardiovascular surgery for coronary artery disease. This includes coronary artery bypass surgery, angioplasties and stents. These were designed to spare one from fatal and nonfatal heart attacks. I think these procedures should not be done. We have multiple trials comparing doing them versus taking care of people conservatively, and these studies show that essentially no patient is advantaged by these interventions.
Thesecond would be arthroscopic surgery for knee pain. Again, studies show that patients gain no advantage from arthroscopic surgery.
Doctors also know little about back pain & how to relieve yet perform many medical procedures sometimes leaving the patient worse off.
Although the article is from 2012, Dr. Hadler raises some good points in a superficial way. For anyone looking for a more in depth take on whatâs known as medical reversal (identifying those interventions that can be demonstrated to have poor outcomes before those poor outcomes occur, I can recommend an excellent book on the topic called, unsurprisingly, Ending Medical Reversal by Vinay Prasad.
However, to the point specifically of interventions in cardiovascular disease (which doesnât just involve the heart, of course) as itâs directly related to the thread start. Sort of. Itâs true that a good many of these donât actually live up to the promise they held. One reason you rarely read about is that a good many of them end up being prescribed to folk who they werenât actually developed for and this reality clouds the issue of benefits vs. risks.
See, a good many of these interventions are the result of a search years/decades even before their widespread introduction to the market and for a specific patient baseâŚthose folk who, in spite of their best efforts cannot overcome the genetic predisposition to, say, ASCVD with its heart attacks, angina, stroke etc.by way of a familial hypercholesterolemia. Whatâs happened over the years is that theyâve been used increasingly on patients whose disease state, as you rightly point out, is due entirely to their choice of a craptaculous lifestyleâŚand who continue eating and sitting their way to further disease even after, say, coronary artery bypass surgery or stent placement. Obviously, the results of interventions in this scenario isnât likely to be as successful ⌠and may even have more unintended consequences ⌠than if such treatments wete reserved only for those patients they were developed for and initially tested on.
I recommend the book, " Ending Medical Reversal: Improving Outcomes, Saving Lives," by by Vinayak K. Prasad.
It details hundreds of medical procedures, devices and drugs that do not have proof of efficacy but are still in widespread use.
It also details the bad advice of doctors to breast cancer survivors (to avoid exercise after surgery) when controlled studies show that exercise reduces lymphedema and reduces the risk of recurrence by 50%.
I would reject any drug that did not show a survival benefit. NOT benefit defined by the measurement of a specific test (e.g. cholesterol) but actual survival.
Wendy
A short video by De Lundberg on bottom line medicine & the AMMM:American Medical Marketing Machine.
8 minute video by dr Nortin Hadler on Coronary Bypass and Angioplasty
In his book he considers the coronary by pass surgery as type II malpractice-a unnecessary procedure done very well by the medical profession.
Like gastric bypass/stapling/sleeves, first for super morbidly obese patients that showed benefits IF they altered their relationship with food. Now, people that are 20-30 pounds overweight the should just go to the gym are getting the surgeries.
One could say the same about knee arthroscopy. Probably way more helpful for the athlete, as far as returning to competitive level, than the weekend warrior or sedentary couch surfer.
Jim Fixx, IIRC, had a single coronary artery (instead of 2) so get a blockage or âeventâ high up enough, no chance for collaterals that aerobic athletes develop to save him. Ditto with Pete Maravich.
You canât look at a number in isolation. My total cholesterol is 220. High even by old standards. But my HDL is around 100. Which accounts for the high cholesterol. Ditto with glucose screening. You can have a normal glucose and even normal A1C but if your insulin level is high, it is a warning your pancreas is working overtime and things arenât as great as they seem to be.
Many problems can be solved by a better diet and exercise but some people were dealt a genetic bad hand. Too many people are too (insert favorite excuse here) to be bothered until the problem is bad.
In 1984 I was hospitalized for ten days with a cardiac condition. After that I saw my sailing friend and cardiologist on a regular basis. Years later a friend of mine, my age, said to me (more or less), âI had an angioplasty and Iâm as good as new.â I asked my cardiologist about it and his reply was that angiograms and angioplasties should be procedures of last resort because they damage (scratch?) the arteries. Twelve years or so later he recommended an angiogram. After the procedure, still on the operating table, he said to me, âYou have a 90% blockage in a coronary artery and I suggest an angioplasty right away so as not to have to repeat procedure later.â I agreed and I got a J&J stent which is still with me 25 years later.
My doctor retired so I had to find a new one. After a stress test this doctor recommended an angiogram to find out what was going on. I decided to get a second opinion which was, "An angiogram is the prescribed procedure." I asked if it was urgent. âNo.â âDoctor, since it is not urgent it isnât happening.â
The problem that the above reveals is that the medical profession does not go for minimal intervention but for maximum treatment.
By the time of this last visit I had already lost a lot of weight and my blood tests were coming out normal. One after another I got rid of the eight medications that I was told were for life. Five or so years later Iâm rid of heart problems, type 2 diabetes, high cholesterol, and all other obesity induced ailments. Itâs all part of being as self reliant as possible.
The Captain
My friend that had the angioplasty later had a triple bypass.
Executive summary of a very long post: do your own due diligence and be your own advocate, rather than blindly following the recommendations. You are an individual for whom a statistically significant data point from a study may or may not apply.
Looks as though my battle with DHâs cardiologist will get more heated in that case. The approach of just looking at LDL totals for decisions on taking meds to control your levels, is simplistic at best and potentially dangerous. More rigorous testing than the conventional lipids profile should be the norm these days, breaking down both the LDL and HDL into levels of dense or âfluffy,â which is admittedly descriptive but a tough term to accept as scientific. Last time I checked the literature, (and I recommend The Great Cholesterol Myth by Bowden and Sinatra for an easy to follow yet not simplistic explanation of the issue,) it was yet unclear if all LDLs were bad and all HDLs were good, rather it depended on the density of each, with fluffy LDLs potentially being good and dense HDLs potentially bad. The ratios of the lipids is probably more important, with the ratio of HDL to Trigycerides looking to be the most predictive of heart disease. LpAs are also an indicator to track, as your more conventional lipid profile may look perfect, but the LpA may indicate a silent heart risk. https://www.heartuk.org.uk/genetic-conditions/high-lipoproteina#:~:text=Lipoprotein(a)%20is%20a%20lot,Lp(a)%20for%20short. Further, an important factor in keeping your arteries clear is getting enough Vitamin K2 in your system, particularly if you take calcium supplements or consume foods containing Ca. Vitamin K2 is critical in your body being able to transport Ca out of the bloodstream where it can do damage, and to the bones where it is beneficial. When I mentioned K2 to DHâs cardiologist, he knew nothing about it.
DH has been a Type 1 diabetic for about 50 years. We have low carbed for about 20 of those years and exercise regularly. He has a 30 inch waist, doesnât smoke and has probably less than 4 drinks a month. He has a calcium score that indicates a heart of a non-diabetic 10 years younger, and his lipid ratios are off the charts good. There is no sign of inflammation. Cholesterol testing with differentiation shows an elevated level of the light and fluffy version of LDL and HDL, vs the dense versions. Yet because his total cholesterol and LDLs are high, and he is diabetic, the cardiologist is constantly wanting to throw him on statins, supposedly because he is diabetic, though the cardiologist could not answer the question of does it matter that he is a type 1 with a non-insulin-producing pancreas, rather than a type 2 insulin resistant diabetic. I wish it were as easy as changing cardiologists, but finding one who is a scientist that evaluates the data rather than someone who simply follows if than statements blindly, (if diabetic and LDL more than X, then statins,) is near impossible. We left the last cardiologist because of their insistence on over prescribing blood pressure meds to reach the previous recommendation, something which was making DH pass out from low blood pressure when he stood, putting him at greater risk of concussion than heart attack.
Studies run to evaluate meds develop generic guidelines that may or may not work for an individual. Instead of predicting how an individual will react to a med, it shows a likelihood that the med will be safe and effective for the general population. Unfortunately, these generic recommendations are being used as must do rules for everyone. Further most studies are done on white men, something which is happily starting to be changed to a limited extent, but still have an impact today. Knowing this, when DH first got put on statins and quickly developed muscle pain in his legs, (which I, not his cardiologist, had warned him to look for,) he went back to the cardiologist for re-evaluation. This time he had in hand a research paper I found in googling that showed non-Caucasian men processed the statin differently from the test subjects and needed half the dose. DH is of Japanese ancestry. At least that time the cardiologist in question had the grace to thank us for the information as she halved his meds. That was the start to my googling the cholesterol issue, and he has since gotten off statins entirely, since our healthy lifestyle and frequent monitoring does not indicate a need for it in our opinion.
I was a research chemist, not in the pharmaceutical industry but trained on how to design research and to evaluate itâs design limitations. These studies have value, but that value must be considered with the limitations in mind. Evaluate yourself as an individual. You may not be average.
Thanks for your excellent and thorough post. For years, I have had the same discussion with my doctor who wants me on statins even though my good cholesterol is as you described your DHâs above, and my total number hovers around 200. I always research every health indicator in depth and have refused to take (to my mind) unnecessary medication. I hate take any pills and luckily just need my morning thyroid dose. But itâs a struggle with my doctor every year at my physical. All numbers are great except he has this thing about statins. My partner has higher cholesterol and so takes the stains. She refuses to give up sugar and simple carbs which would help that number, but thatâs her choice. Which, as a 25 year low-carber, irks me because I know her numbers would improve naturally. Lol. Again, thanks for the concise argument. Going to copy and paste what you wrote and email it to her.
Read a medical article the other day on HDL and it has a U shaped risk curve, i.e., below 40 bad and above 80 bad. The increase in risks were for cardiovascular diseases.
But again, canât really look at one number in isolation.
Some years ago, there was a move in California to remove soda-pop vending machines from public schools. Blowhards like Sean Hannity had an apoplectic fit over âthe peopleâs republic of Californiaâ trying to discourage kids guzzling pop. That is the attitude you have to deal with here in Shiny-land when you do anything to encourage a healthier lifestyle.
Yes, the âhigher the betterâ mantra for HDL definitely seems to be an example of past tense thinkingâŚand appears to have lost its health halo quite a while back.
Interesting that you caution about looking at one number in isolation as something like that has repeatedly been the message WRT my âslightly elevatedâ LDL. In the context of my high HDL, low triglycerides, VLDL, hs-CRP (.6) super Righteous and Healthy lifestyle choices etc, it was allegedly of no concern. Seems a bit ironic that to be taken seriously for diagnostic purposes these days, you almost need to be an overweight Sedentarian (plus a smoker, for good measure). Healthy lifestyle choices serve as a smokescreen.
Even my new PCP seemed fairly agnostic on the benefit of measuring my circulating insulin, Lp(a) particle and Apo-b lipoprotein and CAC scanâŚuntil the results came back. My Lp(a) was super high ⌠strongly associated with the familial hypercholesterolemias and not amenable to change by lifestyle choices.
P.SâŚand piling it on even more, dh is still on a follow up schedule after his open heart surgery with a fancy 3D scan with contrast. At 74 and with a RLQ (Righteous Lifestyle Quotient ) about 80% of mine, thereâs not so much as a single spicule of hydroxyapatite in them there coronary arteries!!
) about 80% of mine, thereâs not so much as a single spicule of hydroxyapatite in them there coronary arteries!!