Melissa, very refreshing.   I'm shocked at how many people have 'normal' fasting glucose < 100 mg/dL or 'mild' impaired fasting glucose 100-110 mg/dL and when we perform glycomark 1,5 AG (2 week postprandial glucose test) through Atherotech labs (very inexpensive) or A1c testing in the office (very inexpensive) and the values are 5.8-6.1% and we perform hospital lab fasting insulin/glucose and then 1 and 2 hr OGTT how many people have high risk IGT or overt DM2.

As you also stated ~ 5-10% of these people are skinny with 'healthy diets'.  Likely some expression of LADA.   Also many of these people have been on low fat diets packed with simple carbs increasing their expression if insulin resistance and glucose disposal problems.

Anytime I see remnant VLDL3 or IDLc elevations or dense phenotype LDLc expression by VAP direct density gradient ultracentrifuge (again inexpensive) I become very worried there is a glucose lipoprotein problem. 

I have probably performed more 2 hr OGTT's in the last 12 months than I had for 15 years only matched by my early career when I used to deliver babies.

I see many clinicians that don't want to 'label' their patient as diabetic but then must address the ACS, MI, STENT, CABG.  I saw a new patient 65 year old gentleman 2 stents 5 years ago came in with 'borderline diabetes' as part of his history who we had to perform 2 v CABG on 6 weeks after his first visit when he developed 'chest symptoms' like he had 5 years ago.  He should have been on glucose modification diet, rx tx as well as treatment of his remnant VLDL3+IDLc, high Lpa-c and dense LDLc way before he saw me.  His glycomark was under 10 and A1c 6.6% 'borderline'  monostatin therapy can't address all of that.   He was bound to have another cardiac intervention. Fortunately he is doing very well and we are making changes that hopefully will make the new plumbing last 20 years. 

Melissa,

Dr Robert Atkins stressed this as a necessary test in all the patients he saw in his practice and EVEN RECOMMENDED doing up to a 3-Hr GTT as a mandartory screening test ....Kudos for this editorial.. but then they also considered his diet heresy as well

Melissa:

I agree with your "heretical statements" on the danger of glucose levels.  I plan to emphasize these points in my campaign to educate people about root causes of MI and stroke.

Ross McCabe, MD

Twitter: @every30secs

thanks Ross. Spreading the gospel of lifestyle change to "cure" about 95% of type II diabetes is paramount to any prevention campaign.Congratulations on your dedication and Keep up the fight!!!

John, I spoke with a patient just yesterday who is terribly worried about her son's glucose intolerance and obesity. I copied and handed this piece to her and asked her to give it to him. Maybe he will take it more seriously. 

Mike, haven't heard from you in a while and you have been missed!  I am glad you mentioned this great clue hidden in plain sight that diabetes is afoot: elevated triglycerides!!! It is a common trigger for me to order a GTT.

DWS, though I don't advocate the Adkins diet, we learned invaluable information about carb intake: lowering carbs will literally make fat melt away....and greatly limiting carbs elminates the root cause of most dyspepsia. Many a patient has had their indigestion"cured" by decreasing carb intake! 

great posts and thanks!!!

Melissa

Melissa,

I agree with the above posts. This was sooo refreshing to hear.  I daily come in contact with providers including cardiologists (sadly) and patients who will not take their insulin resistance/glucose intolerance seriously if it's "not diabetes".  I had a hospitalist tell a patient recently that her blood sugar "was just fine and she wasn't a diabetic" after I'd FINALLY convinced her of taking her glucose levels seriously with a HbA1c of 6.5.  It was back to the drawing boards.  I too could bash in my head with frustration at this level of nonchalance by both providers and patients when in that IR/glucose intolerance-before-actual-diabetes stage with its associated high CV risks.  

I am passionate about reducing these CV risks and along with checking for IR will monitor advanced lipid testing, recommend weight loss in all of my patients who are overweight, point out the associated risks of IR including inflammation, plaque rupture, etc.  I think some patients are just too steeped in denial to want to do anything but others finally get the light.

I will post this blog at the Free Clinic that I volunteer at, another place where I often see the retired providers telling patients that they don't need to worry about their fasting blood sugars of 105 or HbA1c of 5.8; bash, bash.  We have a lot to overcome I'm afraid but patients deservve our persistence.  

Diane Racine, ARNP 

Melissa,

You are correct about testing early. The problem is the lack of a test to measure insulin resistance. Glucose level problems show only when the pancreas has been worn down enough to not be able to produce enough insulin to lower the glucose number. Maybe a measure of circulating insulin replacing the glucose level would be the true alert that is needed.

Chuck 

Melissa,

Cudos for a great post!  I work in a Heart Attack and Stroke Prevention Clinic at a hospital, and we are constantly faced with patients who have elevated fasting glucose, elevated insulin and positive CIMT's who have been told by their physicians that they did not need to worry about their "borderline"diabetes.  It is an uphill battle to try to convince them to lose that abdominal fat and cut down on the carbs they have been inevitably consuming as they try to eat a "low fat" diet. Lack of understanding about nutrition is what we have to spend most of our time discussing!

 Fellow heretic,

Allison

Anon,

No advocating medical therapy. Advocating a cure.  Patient's are far more apt to participate in curative lifestyle measures once we prove to them they have the disease. You won't do that with a " normal" fasting blood sugar.

Melissa

Thanks Melissa,

 I found the forum was raising my blood pressure.  Too many nonclinicians thinking they treat patients.  I have found when we do identify diabetes or impaired glucose with glucose tolerance testing that many patients are now WILLING to participate in lifesyle managment.  Fewer calories, fewer simple carbohydrates, more exercise.  Move the muscles and not the mouth.  Yes when TG's are over 150-200 and HDL is under 40 it is pretty easy to assume these people have abnormal glucose metabolism.  50% of US adults with 'normal' TG's will have TG rich remnant lipoproteins (VLDL3+IDL) dense LDLc phenotype and usually low HDL2 when you perform density gradient ultracentrifuge.  These lipid changes will predate the diabetes diagnosis by more than 10 years.  Thus I have found if people have high RLP's, Dense LDLc B/AB and low HDL2 (with normal HDL).  I will perform glucose testing aggressively.  I don't know if medications will prevent events in these folks but lifestyle is WORTH A LOT.  All the best in 2012 

more interstingly i wish i could have the guts to make more heretic statements especially in front of the boss and not get the sack or communicate opinions via different mediums to fellow colleagues without receiving daming feedback and almost demanding apology just because they disagree with you. and then these so called fellow professionals will treat you with silence next time one sees them.

keep up the heretic Dr walton-shirley....i find it inspiring and gives me confidence to speak up more often ..even if it offends some.

A most refreshing ‘heresy’. Just one problem: how do I get this message through to young (<50yr) women?

It’s difficult to discuss body weight today without being called a health fascist. Right, you can discuss it with your patient, but you can’t discuss it out there with the general public, and to save lives, that’s where we need to go.

If it’s female body weight you’re also an anti-feminist. Fat-shaming. Body-snarking. Discriminating. As a woman, you're a back-stabber, propagating unsound (anorectic, aesthetic) body ideals. End of discussion.

For god’s sake, love and respect and value yourselves, my sisters. Tell yourselves you’re worth it (and it’s not about the cosmetics this time). You’re worth a smoke-free life.  A life without the metabolic syndrome, without diabetes, without cardiovascular disease.  A life where your back/hips/knees won’t give out all of a sudden and require surgical intervention because of too great a load too long. You’re worth safe pregnancy and safe birth of a healthy child. And should you ever need surgery, you’re worth safe surgery, safe anesthesia and speedy recovery without complications, and sorry, that’s far less likely to happen if you pack those fifty to one hundred and fifty pounds extra.

Being and remaining fat has become a feminist RIGHT – everything becomes somebody’s RIGHT these days. Well, sure, women are subjected to discrimination and tradition in many areas of life – less access to physical activity and “me-time” and probably more access to food. Far more effort is devoted to the /health/needs of the male partner in a traditional household. (Equal possibilities to adopt a physically active lifestyle has for some reason NOT become a feminist issue, while the right to adopt traditional male smoking and drinking habits have.)

You may even argue that as women, we stuff our mouths to comfort ourselves and silence ourselves; it’s sometimes the only outlet. Sadly, this is probably true, though I wish that fact would generate the big outcry of rage, not the efforts to combat the overweight epidemic.

I can go along with the concept that obese people – obese women – are victims. But as a Health Professional I refuse to be painted as the enemy. And that’s where I beat my head against the wall. 

Mike,

Love your aggressive stance. Welcome you back to the forum anytime!!!

Garry-the truth shall set you free. It has always protected and served me well. Keep up the fight!!

Anna, I don't feel the least bit gun shy about approaching the issue of obesity in young women.  I start by staying that unfortunately, humans who are 30 pounds overweight are 300x more likely to die a death of cardiovascular disease and cancer. I then explain the  mediterranean diet and give them literature. I bring them back in 4 weeks to see if they are managing. I explain the need for exercise. I also explain that it is our responsibility as individuals to reduce the cost of our existance as much as possible so we can stop spending money on preventable disease so we have enough to spend on "no-fault" maladies.  Do it every day and after a week, it will be old hat. Make no mistake though, it it a stinging revelation for some, however most folks laugh and say, " Now Walton-Shirley, you know I'm a lot more than 30 pounds overweight!", and the conversation gets even easier from there.  Thanks for a great post!!!

 Allison, don't you feel you do a lot of education that should be a basic part of the elementary school curriculum. We need to start there teaching that just as one would not add diesel to a gas tank that requires premium unleaded, we shouldn't fill up our tanks with junk.  Our entire elementary curriculum should be revamped, not just to prepare a youngster for corporate survival but for basic human survival as well. The barbed wire and thicket of modern life are now colas, candy bars and couches.  

Melissa

Rather than measuring the glucose which plays a role in disease,why not show your

patients the more complete story of the role obesity plays in  ill health outcomes.

For example, look at this:

http.//atvb.ahajournals.org/ powerpoint/27/5/996/F1 

William,

I don't want you to get the wrong impression. I absolutely stress the role of obesity in hypertension, cancer, diastolic dysfunction, clotting,etc. etc.  We should consider it negligent if we do not educate the person on the specifics of the physiology of obesity.

Melissa

Well, unfortunately, most of us others have. The very lean type-2 diabetic (not MODY) without the slightest trace of a 'beer belly' does exist, and he/she is not even uncommon. I left Internal Medicine for the ICU many years ago, but not before meeting my share of lean DM2ers. It surprised me then, and I was even more surprised that such a large proportion of them had very aggressive cardiovascular disease.

It may be that I come from a part of the world (Northern Europe) where the obesity epidemic hasn’t struck nearly as bad as in the US – perhaps that makes the lean DM2er more visible here. (I e in the US, (s)he’d be fat, but (s)he’d still be a DM2er even if lean.)

And I do not believe that’s because we’re less into physical activity – the other factor that improves your insulin sensitivity regardless of WC/BMI – quite the contrary. (We’re not conjoint twins with our cars. There are sidewalks and bike paths everywhere and we use them. Both sexes are encouraged to be physically active. Gym cards are economically affordable for everyone, and participation in many types of physical activities is heavily subsidized or free.)

The other reason – you never meet as many diabetics as you do in the ICU. During critical illness or after major surgery/trauma almost everyone becomes a (transient) type-2 diabetic. You’re surprised every time somebody doesn’t need insulin. Believe me, it’s not because we do a decent job of feeding them – we don’t, they practically starve – and it’s not because we feed them iv glucose only, because the vast majority of kcals are enteric. (It’s not because we adhere strictly to the original van den Berghe-concept – we got too much hypoglycemia, but letting them hit 12-14mmol/L is of course not accepted.) Most aren’t on steroids. Of course, the proportion of patients with high BMI or increased waist/hip ratio is increased compared to the general population - but a large part still have perfectly normal WC:s. And – I’ve had the dubious pleasure of inspecting several remarkably fat-free diabetic innards – either in the OR in those who have undergone abdominal surgery, or in the Pathology Dept. in those who have undergone autopsy.   

Now, the critically ill patient is of course a very special case – his/her hormonal and metabolic situation is still largely ‘uncharted’ and nowhere near that of your Cardiology or Internal Medicine outpatient. But – not belittling the risks of obesity, abdominal fat, or the worst of them all – physical inactivity – it’s  a good starting point for the notion that there are most definitively other factors at play here.

We may make up rules of thumb, but nature loves to break them. 

Disclosure of interest: the OGTT tastes like “¤%&*$. (Been there, done that, almost puked.) And two perfectly lean flat-bellied DM2ers with very aggressive disease were also my close relatives.

Yours Sincerely, Annia

Anna,

I've noticed that patients of East Indian Descent are more usually "lean" type II diabetics where as most caucasians living in America are moderately obese diabetics. I think there is definitely a huge genetic issue here or at least genetic modifiers are at play.

Melissa

Hi my name is martha 35 age    quetion . I am diagnose with borderline since march 2012  second test may 2012. my doctor brushes it off  I changed doctors no results this  is the second. hate to be pusshy but I cant stand the pain. On march 2012.  I went to the hospital and after 5 hrs. waiting in terrible pain he touches my back one time and says ''YOUR DOCTOR AT THE CLINNIC YOU GO HE WILL TREAT  YOU THERE'''  and discharges me and barelly walkin.  Then my regular doctor brushes it off again. Is there a reason why doctor wont see you for boderline diabetics and how come they brushes it off also. Why wont doctors do futher testing on all patients . Very disapointed in doctors know  in days.  The doctor will let you in for fourty five minutes and discharge you fifteen  minutes just to bill you. I  live know in south , south texas and I have notice I am not the only one with this problem FAMILY , FRIENDS, STRANGERS ON THE STREET AND THE PEOPLE ACCROSS THE FENCE.  whats happening someone pease give me some answers  I not abe to  lift  barely move ,severe pain , vission is getting worse by the second and I had to let go off my wonderful work working with odyssy hospice.  HELP  THANK YOU MARTHA