Futility of Blood Sugar Lowering by Medications in T2D - T2D 15 - Intensive


(Josh) #1

https://intensivedietarymanagement.com/ukpds-futility-blood-sugar-lowering-t2d/

Hey everyone, I just wanted to share this as a half-hearted defense of physicians treating people with type II diabetes. I hear Richard almost every podcast mention that with each % increase in HbA1C there is an increase in risk for diabetic complications and then state that as physicians our goal is to only lower the blood sugar to an HbA1C of 7 because we are concerned for hypoglycemia and malpractice lawsuits. While there may be some truth to that the whole story is much more complicated and I think is worth knowing especially if you are on medications for the treatment of Type II diabetes.

The fact of the matter as most of you intelligent folks on these forums probably know Type II diabetes is a disease of hyperinsulinemia (elevated insulin levels) but is usually treated by physicians as a disease of hyperglycemia (elevated blood sugar levels). After metformin the majority of medications used to treat type II diabetes (until very recently) do so by increasing insulin levels or supplementing insulin directly. This makes sense if you are treating a disease of hyperglycemia but not if you are treating a disease of hyperinsulinemia. Because of this when we control blood sugars more tightly with medications that increase insulin we worsen mortality. This is the reason that physicians donā€™t try to lower your HbA1C with medications lower than 7-8 depending on your age and other medical problems. It is not as much fear of hypoglycemia (although that is an issue) but instead fear of worsening your overall mortality. If you are taking medications other than metformin (especially insulin) you should not be trying to lower your HbA1C lower than 7 instead you should be titrating off of those medications before lowering your blood sugar further.

This is completely different than lowering your blood sugar through a ketogenic diet and/or intermittent fasting which also lowers your insulin levels and therefore will improve your mortality. Once you are off the other diabetes medications then go hog wild and lower that HbA1C as low as you want!

I hope this is helpful to people out there, I just threw this post together quickly as Iā€™m in a rush but I will check back later to engage in any conversation/questions people have. I love the podcast and the community here on the forums!


(Michael Wallace Ellwood) #2

I would be interested in knowing how Metformin works, if you, or anyone, can explain the science behind it.

Much as many of us would prefer a totally diet-based approach to hyperglycemia, I can see some sense in taking Metformin in certain cases (although not instead of LCHF/keto, but as well as).

It seems to be one of the least worst of the medications in this area of medicine, and statistically, seems to increase longevity (or so I have read).

I presume that it must gradually lead to a decrease in basal insulin levels, and hopefully this should lead to a virtuous circle of reduced BG. Ideally of course, all this taking place against a background of LCHF, or LCHF/keto eating.


(Keto in Katy) #3

I appreciate this post and hope it leads to a better understanding of T2D treatment. The goal here is to provide people with reliable information that they can use to improve their health, so I hope this adds to that conversation.


(Todd Allen) #4

Josh, if doctors understand T2D as a disease of hyperinsulinemia it does make sense to not over do lowering blood sugar by raising insulin. But if the majority of doctors understand that hyperinsulinemia is the root of the problem one would expect insulin testing would be far more common when there are signs of metabolic syndrome instead of relying almost exclusively on the various tests of blood glucose. And why do most believe dietary fat, the least isulinogenic macro, is most problematic?


(Josh) #5

Hey MIke, thanks for the comment. Iā€™m a big fan of Metformin and while Iā€™m generally in favor of limiting medications whenever possible Metformin is one that I have no reservations prescribing when it is appropriate. The main mechanisms are related to decreasing glucose production by the liver and increasing insulin sensitivity (Iā€™m not sure of the mechanism off the top of my head). Because of this it lowers blood glucose and insulin levels which is why it is such a fantastic medication. You are exactly right about some of the proposed longevity/anticancer benefits that have been proposed and are being researched. While this has not been completely proven there are very interesting findings in the data so far.


(Josh) #6

Thanks for the response Todd. Iā€™m not sure if I was completely clear in my original post. Iā€™m a practicing physician and while I believe that most of my colleagues have an inkling that insulin levels are elevated in type II Diabetes they are far from considering that as a significant part of the disease and therefore the majority of people in healthcare are still treating this as a disease of hyperglycemia which is why we donā€™t treat it effectively.


(betsy.rome) #7

Going for a physical tomorrow, so thinking of things to ask my doctor.

Is there any advantage to taking extended release Metformin vs. regular Metformin for T2D? My last HbA1c was down to 5.4 with taking 850 mg 2xd regular Metformin with a ketogenic diet. Iā€™ve been taking Metformin for 12 years.

Last fasting insulin was 2.7, which is low, but my fasting BS was 103, a bit over target. Home testing lately is closer to 90.
Still taking blood pressure meds to stay in normal range, and still on pravastatin with total cholesterol of 207. I assume that means Iā€™m still hyperinsulimic in some way despite lower A1c and insulin.


(Keto in Katy) #8

Is there any talk among your colleagues about reversing T2D by addressing insulin resistance rather than ā€œmanagingā€ the symptom of elevated glucose ā€” or is it still considered a chronic and progressive disease?

It seems to me that as long as the default protocol is focused on the symptom then the medical community is failing these patients.


(Josh) #9

Hey Betsy,

First off just to be clear I canā€™t treat people over the internet but I would love to give input for you to talk over with your doctor, when I can. I donā€™t think there is a significant difference in blood glucose control with extended vs immediate release, the main difference are adherence due to it being once daily and people generally have fewer GI side effects.

Sounds like youā€™ve made great progress and your HbA1c is awesome, I wouldnā€™t stress over the fasting blood sugar as some people can run higher than others, as long as your insulin and HbA1C are normal then Iā€™m not concerned about your fasting blood glucose in that range.

Iā€™m not sure about the blood pressure, there are a lot of factors contributing to that (weight, exercise, etc) and I donā€™t have all the information.

As far as the Statin there are other questions as well. If this is primary prevention (meaning you have not had any cardiac events in the past) I would talk to your doctor about a trial off the medication and rechecking your biomarkers without the medication as that class can have adverse effects on diabetes. I would not be at all concerned about a total cholesterol of 207 but there are a lot of other factors and I donā€™t have all the information.


(Josh) #10

Stacy,
I wish I had better news for you but the medical establishment is a massive slow moving ship and change can be very slow. Most physicians practicing currently were taught to treat blood sugar and donā€™t know any other way of doing things. There are some of us who are trying to change that but we are definitely in the minority. That is why it was a ā€œhalf-hearted defenseā€. I donā€™t think most physicians are doing a very good job treating their patients with diabetes but I also understand why they are doing what they are doing under their current paradigm and with their current medications.


(betsy.rome) #11

Josh, thank you for your reply. THAT is why this Forum is so great!
Iā€™ll ask my doc about the XR Metformin as I do have some GI issues, but donā€™t know if theyā€™re related or not. Iā€™ve been taking Metformin for 12 years and have had IBS for a similar time, but correlation does not equal causation. How long would Iā€™d have to be off Metformin to see if itā€™s responsible?

Re: statin - Iā€™ll ask again, but last time she recommended staying on the statin. Since my father had a triple bypass when he was 65 ( Iā€™m 62 ) pretty sure she will want me to continue on the statin even though my CRP is low (0.3 mg/L).

Re: statins causing T2D - well, that ship has sailed for me, but whatā€™s the effect on a recovering (keto) T2D? Do statins raise BG and/or insulin in T2Dā€™s who are in good control? I looked for studies but didnā€™t find that.


(Brad) #12

(Josh) #13

I would love it if we had a medication that cured diabetes and perhaps someday this will come out but I will still push people to cure themselves through lifestyle as anything with such promise also will likely have a huge downside.


(Josh) #14

Hey @betsy.rome You have really opened a can on this one. Thereā€™s a lot of data out there about statins, some shows a decreased risk of cardiovascular disease, not much of the ā€œconvincing dataā€ is in women or those using it for primary prevention meaning they havenā€™t yet had a cardiovascular event. There are tests out there such as the coronary artery calcium score that may give you a better idea of what your actual risk is and how close you are to your Dadā€™s scenario but I would wager that he had some risk factors that you donā€™t and didnā€™t try to decrease his risk through the ketogenic diet. All that being said I am not your doctor and I wonā€™t make that recommendation but I think it is something you should discuss with your doctor and stopping this medication for a period of time to recheck your numbers should not make a significant difference in the grand scheme of things. At the end of that if they still insist then maybe you should consider a second opinion. As far as the mechanism by which statins ā€œcauseā€ diabetes I donā€™t think that is clear, there are theoretical mechanisms but they seem to worsen insulin sensitivity and I would be very interested to hear if you had any change in your fasting glucose HbA1C or insulin numbers if you stopped

As far as the metformin a few days off should be enough to see if that is the culprit, 1 week if you want to be absolutely certain.

p.s. Iā€™m sorry about the statin rant Iā€™m sure there is a lot more information about statins on this forum that would be worth exploring


(betsy.rome) #15

At my yearly physical yesterday, spoke to my dr. about statins, metformin. Decided to try the XR metformin 1x/day for 3 months vs regular metformin 2 x /day, to see if any change in GI symptoms, and Iā€™ll check my BG at home for changes. Will recheck labs in 3 months; one thing at a time. After that, if I want to, I can try going off the pravastatin 40 mg to see how that affects my lipids.

Re: data about older female keto T2Dā€™s taking statins without a previous heart event. @Dr_buenhombre - Can of worms indeed. If someone doesnā€™t get a heart attack, how do we know if the statin is responsible? My doc thinks the up-side of statins for someone like myself, outweigh the possible down-sides.


#16

I have been on Metformin for 13 years. I went 100% ketogenic nine+ months ago. Lost about 80 lbs, got off 100 units a day of Insulin. But I have stayed on Metformin.I also do Intermittent Fasting so my Insulin levels drop every single day by dinner time.

But I am thinking differently now and I went off Metformin three days ago. The reason I am thinking differently is what the effect of Metformin is said to be. It has to do with Insulin Resistance. The typical claim is ā€œOverall, metformin decreases insulin resistance and improves insulin sensitivity, thereby helping the insulin your body still makes work more effectively.ā€. But does it merely treat or cure insulin resistance?

I know that Metformin lowers my blood sugar. If I miss taking it with dinner I have Dawn Syndrome-ish numbers in the morning that are 10-15 points higher than when I take it. Iā€™ve seen it many, many dozens of times now. So I know it works in the short term.

But my GOAL is to reduce my Insulin Resistance. This made me wonder, does Metformin actually reduce my Insulin Resistance or does it possibly make it worse?

So I took a small step three days ago and stopped taking Metformin. The next day I got the typical bounce up. The second day was bad. Instead of fasting numbers in the morning of 115 I got 145 - the highest number since I went ketogenic. But unlike other times when I returned to Metformin, I thought Iā€™d give it some more time. 140ā€™s for a few hours are nothing and my number dropped by the end of the day to less than 100 so I am well within safe zone.

I wondered what others have had for an experience in quitting and what happened with their blood sugar? I never felt bad on Metformin but I feel even better off it at this present moment.Whey my blood sugar was in the 140ā€™s I felt like crap.

Hereā€™s the reasoning behind my choice to give quitting a chance based on the arguments for taking Metformin (turned around).

ā€œMetforminā€™s main action is to decrease the overproduction of glucose by the liver, a common problem in prediabetes and type 2 diabetes.ā€

Keto prevents these dumps too but I have still seen Dawn Syndrome numbers every day of maybe 110-115 or so. So it seems like the Metformin helps short term but it comes out anyway (like the next AM making my Dawn Syndrome numbers worse). Seems like Metformin may be patterning my liver to dump the next morning.

ā€œMetformin also increases the uptake of glucose by your muscles.ā€

Thatā€™s the one that bothers me the most. It sounds like it has the same effect as Insulin does by allowing glucose to be pushed into my cells. I donā€™t want more glucose pushed into my cells if I am keto. Makes me wonder if it is really just another hormone like Insulin. Why would I want something that does the same thing as Insulin. Sure it might lower the insulin load on my pancreas which seems like a good thing, but itā€™s not a good balance to shift to a drug to do that, is it? If Insulin is both the key to pushing and releasing glucose from our cells then why lock the lock tighter?

ā€œMetformin does not seem to cause weight gain (in fact, you may even lose a few pounds),ā€

Now that one has me really stumped. How does it not cause weight gain in the long run if it makes your cells accept the action of pushing glucose into cells? It makes me think that it really isnā€™t a good choice in the long run. Most of these ā€œI lost studiesā€ are short term and for many may have more to do with the stomach upsetting issues of Metformin. Plus people could have more energy from lower blood sugars (which make you more tired). Once your body becomes used to Metformin thereā€™s no real science reason I can see why it should lower weight. Itā€™s helping glucose be shoved into our cells. This study says no weight change net over time from Metformin (which is at least better than most other drugs).


(Marty) #17

Hi allā€¦ as a newbie, this is my first post. I am a fan of the Two Keto Dudes podcasts, which led me to these forums. A VERY brief into: I live in BC, Canada and was diagnosed with T2D in my early-30s. Now, over a decade later - with the help of keto - I finally feel that I am in control of my own health. I am completely off insulin therapy and lowering my daily dose of Victoza. I was also taking Gluemetza (extended release Metforman), but was working with my endocrinologist to lower my medications, with the goal of completely controlling my T2D with diet. This was my 3rd or 4th visit with her and she is slowly coming around to the idea that I am PRO keto and ANTI medicationā€¦though she had previously labeled the ketogenic diet as ā€œbunkā€. Although she still wants to see me on a statin (as well as my family physician), I am politely refusing based on the fact that their own ā€˜calculationsā€™ put me in a very modest 5% risk for cardiovascular disease, as well as my own (ongoing) research on the effects of statins.

I absolutely see the pattern of how doctors want to treat high blood sugar rather than high insulin/insulin resistance. However, one blood test at a time I am showing them that I can and AM treating this disease with the ketogenic diet, instead of the medications they want to prescribe me.

I wonā€™t say that it was all bad. The doctors Iā€™ve seen have, at the very least, brought awareness of diabetes to my attention. There have been times over the last 10-15 years that I have strayed from their therapy advice and thus paid the price of very high sugar levels (30+ mmol/L and A1C 12.2). But I could ignore it no longer once foot neuropathy had set in 2 years ago.

Currently, I am well on my way to reversing my T2D with the help of keto and the support structure/knowledge base of the Ketogenic Forums and the Two Keto Dudes. My latest blood tests showed a 6.0 A1C, and my typical daily glucose range is between 4.3 and 7-8 (depending on how much I stray).

All this to say I am on the fence whether resuming Glumetza would be a benefit for me or not?

I look forward to reading and learning more on the Ketogenic Forums and I thank everyone who is contributing and walking with me on my keto journey.


(Gabriel G.) #18

Good work! Way to take your life back!