Heartfelt with Dr Melissa Walton-ShirleyView all posts »
They are sweeter than you think: Patients need a glucose challenge to know for sureJan 12, 2012 09:27 EST
I am with English philosopher Thomas Hobbes on this one: "They that approve a private opinion call it opinion; but they that dislike it, heresy; and yet heresy signifies no more than private opinion." So here goes. Here is the statement of a heretic: "Everyone who is 30 pounds overweight needs a 75-g glucose challenge even if they are under the mistaken impression their carbohydrate metabolism is unimpaired." Melissa Walton-Shirley
I admit it feels really good to get that off my chest.
I owe my heretic philosophy to a lecture by Dr P Gabriel Steg that I stumbled upon quite by accident many years ago while in Barcelona, waiting for that year's European Society of Cardiology lectures to begin. I heard a voice echoing down the hall of what I thought was an empty convention center while waiting for another lecture to begin. I followed the sound as I had 30 minutes to kill. I opened the door to a gigantic auditorium where probably a thousand attendees sat listening to information on the now-defunct rimonabant compound. Dr Steg had an amazing PowerPoint that explained the finite mechanism of hormone production of the abdominal fat pad and the horrible metabolic derangements produced by it. I recall understanding for the first time how being "fat" kills a person, how the inflammatory response causes plaque rupture, fluid retention, hypertension, stroke, clot, blockage, and even lends itself to vascular spasm. Gabriel might not agree with this extreme interpretation of his presentation, although I don't know for certain. We've discussed many other things, but I've never had an in-depth discussion on his views of sugar metabolism. I assure you, however, that hundreds of patients in Glasgow, KY have been changed forever by his lecture. I am truly grateful to him.
Heretic statement #2: "More people die of 'borderline diabetes' than true diabetes because it is not given the respect it deserves." Melissa Walton-Shirley
I do not believe in the term "borderline" diabetes. It makes about as much sense as saying one is "borderline" pregnant. You either "are" diabetic or you "aren't." You either have blood glucose of less than 140 after 75 g of glucose or you don't. If you eat a slice of pie and your blood sugar hits 160, you are a type 2 diabetic. Perhaps all you need to do is lose weight, push back the plate, exercise, and reverse it, or you might be one of the unfortunate who need four insulin shots per day. I submit it is the same disease process, just different extremes of insulin resistance. Both versions can spell blindness, diabetes, heart attack, and dialysis.
For laypersons that follow my blog, there is a distinct difference between unfortunate "true" type 1 diabetics who have had the misfortune to suffer the death of their insulin-producing islet cells. They have a completely different disease process. Unless they undergo an islet-cell or pancreas transplant, they will always be a type 1 diabetic and will require insulin supplementation. Contrast this to the typical type 2 diabetic. About 95% of those in my practice are overweight, don't eat properly, and rarely exercise until they receive "the diagnosis." It is amazing to me that about 95% of them have no clue that they are completely "curable." It is a matter of lifestyle change. With rare exception, I've hardly met a true type 2 diabetic who could not get off insulin after losing about 50 pounds. Nothing is more frustrating to me than someone who relates to me, "Well, I'm terribly sick with diabetes, doctor. I've had to go on insulin," while folding their hands in resignation, accepting a fate of dialysis, amputation, blindness, heart disease, and stroke. I really want to shake them out of their complacency.
I do have about 10 normal-weight individuals in my practice who have impaired glucose metabolism and are not type 1. I'll leave it to the endocrinologists to explain it. I don't know if it is production of an imperfect insulin molecule or if there is severe genetic resistance, but they do exist. In Glasgow, KY, they are an extreme minority.
Heretic statement #3: "There is an inherent prejudice in the medical community against the use of the term diabetes even after an impaired glucose-tolerance test is completed." Melissa Walton-Shirley
You have no idea the number of times I have opened the door to a patient who is positively beaming with the fantastic news: "My doctor told me I'm really not diabetic like we initially thought! I'm just borderline!" Yippee! I think as I close the chart over a postprandial blood sugar of 240. I want to then beat my head against the wall until I am unconscious. It would be the only true escape from such indifference to the obvious ability to save lives, legs, vision, and healthcare dollars (in concert with making America smoke-free, of course!). The last patient who argued with me regarding this issue had a postprandial blood sugar of 420 (no exaggeration) who seemed "borderline," convinced at first of his diagnosis.
The new guidelines published on assessment of hemoglobin A1c, although most welcome, in my less-than-humble opinion are a fantastic first step in detection of the disease that kills so many human beings on a daily basis but fall just short of what will actually "make" the diagnosis of so many diabetics. I order a nonfasting two-hour glucose challenge with 75 g of glucola on most patients who present for hospital admission from whatever cause if they have some weight to lose or if they have a single abnormal blood sugar on the chart. I am amazed at the heights to which those glucose levels soar, but it is required that I show it to the patient in black and white before most are motivated to do anything about it.
Heretic statement #4: "If your physician tells you that you are just a 'borderline diabetic,' don't believe it." Melissa Walton-Shirley
Run screaming to the nearest gym, fresh produce aisle, and a good nutritionist.
I'm willing to bet that you are sweeter than you think.