Sugar In and Sugar Out: The Modern Treatment of Type 2 Diabetes

A few days ago the results of a potentially game-changing trial on the treatment of type 2 diabetes and cardiovascular disease (EMPA-REG OUTCOME trial) were presented at an international diabetes conference in Stockholm, Sweden and simultaneously published in the New England Journal of Medicine (1).

For the first time, a study has found that a drug that lowers blood sugar (glucose) also appears to reduce the risk of death thereby improving survival.

Sugar In, Sugar Out: Modern Treatment of Type 2 Diabetes

I must admit that I’ve always found it a bit difficult to understand why we treat type 2 diabetes like we do. Of course, I’m not a diabetologist and therefore probably have a somewhat limited understanding of the disease. However, as a cardiologist I see a large number of people with diabetes, type 2 diabetes in particular.

Cardiologists use drugs to treat high blood pressure because randomized controlled trials have shown that such treatment lowers mortality and reduces the risk of future cardiovascular events. For the same reason, patients with established cardiovascular disease are treated with statin drugs and patients with congestive heart failure are treated with ACE – inhibitors and beta blockers.

Having type 2 diabetes increases the risk of cardiovascular disease. However, although we constantly treat patients with the disease with glucose-lowering drugs, it has not been convincingly shown that such treatment reduces the risk of cardiovascular disease or death.

So why do we treat type 2 diabetics with glucose-lowering agents if it isn’t proved that they improve prognosis or reduce the risk of complications?

And, another thing; Why do we recommend high carbohydrate diets to type 2 diabetics if the aim is to lower blood sugar? All of us know that carbohydrates are just chains of sugar molecules.

So, is there a paradigm shift in the treatment of type 2 diabetes? How does the recently published EMPA-REG OUTCOME trial change our approach to the disease?

For those not very well acquainted with the issue, I just want to recapitulate shortly the difference between type 1 and type 2 diabetes as these are two separate diseases that are approached and treated quite differently.


Type 1 vs. Type 2 Diabetes

Type 1 diabetes used to be called juvenile onset or insulin-dependent diabetes because it often presents in childhood and it is characterized by the inability of the pancreas to produce the insulin.

Insulin is necessary for the cells of the body to be able to utilize glucose for energy production. Without insulin, glucose accumulates in the blood leading to hyperglycemia. Due to the absence of insulin, patients with type 1 diabetes need to be treated with insulin.

Conversely, type 2 diabetes, formerly called adult-onset or non-insulin-dependent diabetes, can occur at any age. Although it is most common among adults, the prevalence is rising among children.

Type 2 diabetes is characterized by insulin resistance. Insulin resistance is defined as a diminished response to a given concentration of insulin. Initially, the pancreas responds by producing more insulin. For this reason, people with insulin resistance often have high blood levels of insulin. However, as diabetes develops, the beta cells of the pancreas often become unable to produce more insulin and its blood levels drop.

Type 2 diabetes is commonly associated with obesity or the metabolic syndrome. Many patients with the disorder also have high blood pressure and lipid abnormalities.

Worldwide, approximately 90% of people with diabetes have type 2 diabetes.

The EMPA-REG OUTCOME Trial

Empagliflozin is a selective inhibitor of sodium glucose transporter 2. The drug lowers blood glucose by decreasing the reabsorption of glucose in the kidneys, thereby increasing urinary glucose excretion. Sounds quite simple; lowering blood glucose by throwing out excess glucose with the urine.

The EPMG-REG Outcome Trial was a phase III, international, multicenter, randomized, parallel group, double-blind cardiovascular safety study of empagliflozin, given at an oral dose of 10 mg/day or 25 mg/day compared to the best usual care in patients with type 2 diabetes who were at increased cardiovascular risk due to the presence of established cardiovascular disease. The study was done at 590 sites in 42 countries across six continents and involved more than 7,000 patients observed over a median of 3.1 years.

The study found that cardiovascular death, hospitalizations for heart failure, and all-cause mortality were all reduced by more than a third (relative risk reductions of 38%, 35% and 32% respectively).

The number of patients needed to be treated (NNT) with empagliflozin for 3 years to prevent one cardiovascular death was 39 which is quite impressive compared with many other commonly used drug interventions in cardiovascular medicine.

Is It About Sugar In and Sugar Out or Something Else?

Of course, the results of the EPMG-REG Outcome Trial raise some questions.

The first thing that comes to mind is whether the effect of the drug is due to its glucose-lowering effect. If a drug works because it lets patients urinate excess sugar molecules one could assume that putting less sugar into the system, by reducing carbohydrate intake, would be just as beneficial.

Interestingly this may remind us of the discussion with statin drugs. Initially, we believed they worked because they lowered blood cholesterol, LDL cholesterol in particular, but then it later turned out that statins have several other effects that may explain why they are beneficial for people with cardiovascular disease.

Interestingly, empagliflozin may induce weight loss, lower blood pressure, reduce arterial stiffness and visceral obesity. All these effects may potentially explain why the drug is beneficial for patients with type 2 diabetes and cardiovascular disease. So, possibly, the reason the drug works has nothing to do with blood sugar whatsoever.

It is of interest to look at the subgroup analyses from the New England paper. Keep in mind that such analyses are sensitive and should be interpreted carefully.

For example, there was not a statistical difference in the primary endpoint between empagliflozin and placebo among patients with glycated hemoglobin > 8.5% but only among these with levels < 8.5%. Similarly, there was no treatment effect in those with body mass index (BMI) > 30 and only those with BMI < 30.

Interestingly, empagliflozin was associated with small increases in both LDL cholesterol and HDL cholesterol. Thus, lowering of LDL cholesterol does not explain the efficacy of the drug.

The Bottom Line

The EPMG-REG Outcome Trial shows for the first time that a glucose-lowering drug given to patients with type 2 diabetes and established cardiovascular disease may improve prognosis and reduce the risk of death.

Whether the positive effect of the drug is due to its glucose-lowering effect or other mechanisms is still a matter of debate.

The authors believe that the mechanisms behind the cardiovascular benefits of empagliflozin are multidimensional and may involve its glucose-lowering effect as well as changes in arterial stiffness, cardiac function and oxygen demand, protective effects on kidney function and positive effects on body weight, visceral adiposity, and blood pressure.

But, still, I can’t help thinking that putting less sugar into the system by reducing carbohydrate intake might have some of the benefits as has increasing its urinary excretion with a drug.



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Mie
Mie
4 years ago

Axel “And, another thing; Why do we recommend high carbohydrate diets to type 2 diabetics if the aim is to lower blood sugar? All of us know that carbohydrates are just chains of sugar molecules.” Yes Axel, it is PRECISELY the same thing to eat e.g. fruits and berries (chains of sugar molecules) as candy and ice cream (chains of sugar molecules). 😉 In addition, dietary recommendations are based on systematic reviews clinical and observational evidence. What are you suggesting? Should the recommendations be based on a bunch of short-term trials where low carb diets sometimes have slightly better effects,… Read more »

Axel F Sigurdsson
Axel F Sigurdsson
4 years ago
Reply to  Mie

Thanks Mie. I´m very grateful that my limited knowledge is able to inspire such a thoughtful and intellectual comment. Just like to follow up on one detail. You wrote: “In addition, dietary recommendations are based on systematic reviews clinical and observational evidence.” I would like to bring that into question. In fact, a systematic review and meta-analysis published in The American Journal of Clinical Nutrition 2013 concluded that “Low-carbohydrate, low-GI, Mediterranean, and high-protein diets are effective in improving various markers of cardiovascular risk in people with diabetes and should be considered in the overall strategy of diabetes management.” https://ajcn.nutrition.org/content/early/2013/01/30/ajcn.112.042457.abstract Interestingly,… Read more »

Mie
Mie
4 years ago

Axel, like your spicy tone. 🙂 However, notice the cause and effect: if you write something as silly as “sugar-is-sugar-carbs-are-carbs”, you’re practically inviting people to be sarcastic.

As for the meta-analysis you cite: you should know that the key here is hard end-point data, not data indicating that lowering carbs is one of the MANY options for diabetics. In other words, if low carb is the best way (as you imply), you need more proof.

Axel F Sigurdsson
Axel F Sigurdsson
4 years ago
Reply to  Mie

Mie,
If there was hard end-point data available (I’m not talking about lowering of LDL cholesterol) on the efficacy of the high carbohydrate approach recommended by so many public health authorities for type 2 diabetes I would probably not be suggesting other options.

Mie
Mie
4 years ago

I’m sorry, but that doesn’t explain why you’d bring up another alternative that hasn’t been tested/passed the same criteria as e.g. Med. diet. What is it about low carb that warrants this special treament?

George
George
4 years ago
Reply to  Mie

I though the content of this post explains that. Not to mention lots of good diabetes low carb research including a couple of long term (4 year) trials with good outcomes.
The question is, what was it about Med diet that warranted the special treatment of being tested over and over again despite middling results?

Mie
Mie
4 years ago
Reply to  George

“Not to mention lots of good diabetes low carb research including a couple of long term (4 year) trials with good outcomes.” Such as …? Which trials are you talking about? The trials I’m aware of show that low carb is pretty much as good an option as many others, certainly not superior. “The question is, what was it about Med diet that warranted the special treatment of being tested over and over again despite middling results?” Err, define “middling”. You do know it’s the option that has the best kind of hard end-point data available in CVD prevention (e.g.… Read more »

michael goroncy
michael goroncy
4 years ago
Reply to  Mie

Mie “Yes Axel, it is PRECISELY the same thing to eat e.g. fruits and berries (chains of sugar molecules) as candy and ice cream (chains of sugar molecules). 😉 “ It appears that you are clueless with regards to to metabolism involved with the digestion of whole fruit. It’s not ‘candy from a tree’ and the mechanism is vastly different than say ‘Juicing’ which drastically spikes blood sugars. The fibre and nutrients in fruit make up part of healthy diet….The day that fruit is declared deleterious is the day you can be cured from health blogs and give up reading… Read more »

Mie
Mie
4 years ago

It appears, Michael, that you didn’t understand my sarcasm. The differences between carb choices are precisely what I meant. To think of carbs as mere “chains of sugar molecules” is therefore silly.

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

Yes Axel, it is PRECISELY the same thing to eat e.g. fruits and berries (chains of sugar molecules) as candy and ice cream (chains of sugar molecules). So you seem to be saying that our bodies are able to differentiate between fructose/glucose that originates from fruit and fructose/glucose that originates from candy and sweets. Please explain to me the mechanism by which that happens. Should the recommendations be based on a bunch of short-term trials where low carb diets sometimes have slightly better effects, due to the fact that they initially lead to more weight loss (which then levels off… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“So you seem to be saying that our bodies are able to differentiate between fructose/glucose that originates from fruit and fructose/glucose that originates from candy and sweets.” Nope. What I’m saying is what Michael stated: fruits and berries have a plethora of healthy nutrients in them which makes their consumption beneficial. “Please explain how you can tell from short term trials the long term effects of a low carb diet.” RC problems again, I see. The point was PRECISELY that you can’t. Therefore you need long term trials investigating the effect of low carb diets on hospitalizations, non-fatal end points… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

Nope. What I’m saying is what Michael stated: fruits and berries have a plethora of healthy nutrients in them which makes their consumption beneficial. So you’re saying that because fruits and berries have a plethora of healthy nutrients that you can ignore the effects of the fructose and glucose content? How does that work, exactly? Why not just take a multi-vitamin and a fiber capsule and skip the insulin spike instead? The point was PRECISELY that you can’t. And yet you specifically stated that in the long term that people who lost weight with low carb gain weight back. How… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“So you’re saying that because fruits and berries have a plethora of healthy nutrients that you can ignore the effects of the fructose and glucose content?” Yes. Fruits and berries have been consistently shown to be e.g. cardioprotective, both in special groups and in general population. “Why not just take a multi-vitamin and a fiber capsule and skip the insulin spike instead?” Because the use of multivitamins – or vitamin supplements – hasn’t been shown to be e.g. cardioprotective in general population and only in very specific. “How do you know this if the clinical trials haven’t been done?” ?????… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

Yes. Fruits and berries have been consistently shown to be e.g. cardioprotective, both in special groups and in general population. Wouldn’t it be apprpriate to assume that people who eat more fruits and berries would generally be more health conscious in general and probably exercise more, drink less, smoke less, get better sleep, take vitamins and all the other things that health conscious people do? I find it difficult to believe you can teas out that these people’s better health is due to eating fruits and berries with all these confounders. Because the use of multivitamins – or vitamin supplements… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“Wouldn’t it be apprpriate to assume that…” Of course. That’s why e.g. epidemiological studies are adjusted for these kind of confounders. And yet, the associations are clear, strong and persistent. In addition, there are several mechanisms as to why fruits and berries are cardioprotective. “Have you ever noticed when you’re talking out your ass that you don’t even attempt to cite any data supporting your case?” Want data of a well-known issue like this? There you go (and not just CVD but also cancer and total mortality, both reviews and meta-analyses): https://annals.org/article.aspx?articleid=1767855 https://www.ncbi.nlm.nih.gov/pubmed/21981610 https://www.ncbi.nlm.nih.gov/pubmed/21981610 https://www.ncbi.nlm.nih.gov/pubmed/21981610 https://www.ncbi.nlm.nih.gov/pubmed/20194238 https://www.ncbi.nlm.nih.gov/pubmed/17846391 https://www.ncbi.nlm.nih.gov/pubmed/18677777 https://www.ncbi.nlm.nih.gov/pubmed/18677777 https://www.ncbi.nlm.nih.gov/pubmed/18677777… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

Don’t you ever get tired of your own bullshit? When I say that your studies didn’t cite anything about a low carb diet it’s because those studies you cited weren’t talking about a low carb diet. It’s not an “excuse”, it’s just that your citations didn’t refer to what you said they did. Your Shai at al was funny – the adherence rate at 2 years was 85% and wouldn’t you know it, the low carbers lost the most weight on average. They also found signitifcant regression in plaque in the arteries. Unsurprisingly, when adherence drops later on and people… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“When I say that your studies didn’t cite anything about a low carb diet it’s because those studies you cited weren’t talking about a low carb diet. It’s not an “excuse”, it’s just that your citations didn’t refer to what you said they did.” Yes, it’s an excuse Bob, just like the ones you’ve made earlier. They’re all studies where people get instructions to follow a low carb diet – just line in ANY OTHER diet studies (e.g. studies conducted on Med. diet, for instance Lyon Diet Heart which showed that Med.diet can reduce CVD deaths) – and where they… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

So we’ve reached the point where I understand I’m either trying to make my point with someone who is either irrational or someone who is… well I guess I’m out of other options. Further discourse is probably a waste of time. But you did ask a good question – “why should people follow low carb diets in the first place if a) it’s next to impossible to meet the carb intake restrictions in long-term trials and if b) reductions in carb intake produce no benefit as such in the first place, apart from those coming from … well, caloric restriction… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

Bob, just because you pretend I’m irrational doesn’t mean I’m one. You projecting, once again. A survival strategy as you simply a) cannot answer the points I’ve made because b) you don’t know anything about the topic and c) cannot understand research literature cited. “First off, people get off low carb diets because …” Ad hoc. If this is the case (in diet studies, which is the topic at hand), surely you can back that up with EVIDENCE. Go ahead. “Your argument is akin to telling smokers that there’s no benefit to quitting smoking because it’s difficult to quit.” Nope.… Read more »

Nigel Kinbrum
4 years ago
Reply to  bob_johnston

Are you really this stupid?
Fruits contain relatively sparse cellular carbs plus fibre.
Sweets contain dense, acellular carbs with zero fibre.

bob_johnston
bob_johnston
4 years ago
Reply to  Nigel Kinbrum

I’ve arrived at the conclusion that you struggle with reading for comprehension. I said that the fructose found in fruit is the same as the fructose found in sugar. They will both have the same detrimental effect on your liver and the rest of your body. Now if you think that the fiber found in fruit somehow makes its fructose affect your liver differently then don’t think you have a good grasp of biochemistry. All people have a tolerance for some level of fructose. If you’re a healthy individual then you can probably consume more than a sick person. But… Read more »

Nigel Kinbrum
4 years ago
Reply to  bob_johnston

You are a classic case of the pot calling the kettle black.

What’s the difference between “relatively sparse” & “dense”?

What’s the difference between “cellular” & “acellular”?

See also https://bit.ly/1aHloAz I’m actually arguing for your case, if you check the comments.

Dose & context make all the difference!

Mie
Mie
4 years ago
Reply to  bob_johnston

“They will both have the same detrimental effect on your liver and the rest of your body. Now if you think that the fiber found in fruit somehow makes its fructose affect your liver differently then don’t think you have a good grasp of biochemistry.”

Here Bob nicely dispalys reductionist thinking stretched to arsurd limits. One ingredient – which is detrimental ONLY when consumed to excess in a certain context – by no means negates the overall positive effect.

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

If you’re insulin resistant and/or have fatty liver disease you probably shouldn’t be eating fruit due to the high-ish fructose content. You can get all the vitamins, micronutrients and soluble fiber you need from meat and vegetables that won’t have any deleterious effects. Eat fruit if you want, but understand it’s not something that you need to consume for good health and in fact it might be hurting you. I’m not sure what else I can say on the topic that will break through the “But fruit is natural and therefore healthy” attitude. Fructose is fructose, I don’t care if… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“If you’re insulin resistant and/or have fatty liver disease you probably shouldn’t be eating fruit due to the high-ish fructose content.” Oh, the “high-ish” fructose content! For instance, one apple has whopping 3-4 grams of fructose! Dear God, no!!!! “You can get all the vitamins, micronutrients and soluble fiber you need from meat and vegetables that won’t have any deleterious effects.” … except that meat doesn’t seem to be cardio-protective, unlike fruit. And, unlike fruit, it tends to increase the risk of certain types of cancer when consumed regularly. Now, of course you can eat meat in moderation. There’s, however,… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

You’re trying too hard. And it shows. Let’s look at the nutritional value of an orange, a fruit nearly everyone seems to think is loaded with beneficial nutrients. A typical orange has 17 grams of fructose/glucose, which is a little over 3 teaspoons. For comparison sake, that’s a little less than half of the sugar in a can of Coke. Sounds great… not. As for other nutrition this wonder food has 4 grams of fiber, 90 mg of Vitamin C and not a whole lot of anything else. What am I missing here? Do you think that preventing a case… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“A typical orange has 17 grams of fructose/glucose, which is a little over 3 teaspoons. For comparison sake, that’s a little less than half of the sugar in a can of Coke. Sounds great… not.” So you decided to move away from fructose to total sugar? Ok. “What am I missing here?” Calcium, folate, potassium – to name a few. Of course, fibre and vitamin C are important enough on their own. “Do you think that preventing a case of scurvy is more important than preventing a heart attack or diabetes?” Nope. But it is PRECISELY the latter two cases:… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

“So you decided to move away from fructose to total sugar? Ok. So picking nits is a hobby for you… good to know. “Calcium, folate, potassium – to name a few. Of course, fibre and vitamin C are important enough on their own.” Those are great nutrients. Too bad an orange has very small quantities of it. You obviously didn’t look at the link I provided. “intake of fruits is inversely associated with DM2 and cardiovascular diseases.” There you go with your observational data. I would tend to bet that people who eat fruit are also the type of people… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“So picking nits is a hobby for you… good to know.” Not really – or if it is, a minor one compared to you & moving goalposts. “Those are great nutrients. Too bad an orange has very small quantities of it. You obviously didn’t look at the link I provided.” Compared to its energy content, not that bad. Plus vitamin C & fibre which – I would say – alone justify having an orance every now and then. Of course, there are better options in the world of fruits and berries, if that’s what you’re worried. The food group itself… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  Mie

Compared to its energy content, not that bad. Plus vitamin C & fibre which – I would say – alone justify having an orance every now and then. My stance on fruit is that the fructose content is harmful if you’re insulin resistant and havefatty liver disease, regardless of the fiber or vitamin content. Fortunately there are many foods where you don’t have to inundate your liver with fructose – eat some broccoli instead. Higher vitamin C and fiber and has a decent amount of vitamin K as well. Better food, a fraction of the fructose. If you’re not metabolically… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“My stance on fruit is that the fructose content is harmful if you’re insulin resistant and havefatty liver disease, regardless of the fiber or vitamin content.” I know, no need to repeat that. You’ve provided zero evidence for this, except that same ol’ reductionist mantra “fructose-is-fructose” which is useless – due to the context. “Fortunately there are many foods where you don’t have to inundate your liver with fructose – eat some broccoli instead.” False dichotomy. Eating broccoli is a very good idea, but in no way should it mean that you can’t have oranges at all. It’s not “either… Read more »

Mie
Mie
4 years ago
Reply to  bob_johnston

“A typical orange has 17 grams of fructose/glucose, which is a little over 3 teaspoons. For comparison sake, that’s a little less than half of the sugar in a can of Coke. Sounds great… not.” So now you’re moving away from fructose to sugar per se. Ok. “As for other nutrition this wonder food has 4 grams of fiber, 90 mg of Vitamin C and not a whole lot of anything else.” And calcium, potassium, carotenoids, folate, to name a few. “What am I missing here? Do you think that preventing a case of scurvy is more important than preventing… Read more »

Robert Alexander
Robert Alexander
4 years ago

Thanks for the usual very interesting post Axel. As a family doctor I’m starting to get confused by the conflicting indications given by different specialists (cardiologists, diabetologists, nephrologists) on dietary guidelines 🙁 For example I had to understand how to cope with a patient whose both diabetic and not uncommonly has a low creatinine clearance with a renal scintigraphy suggesting a 50% reduction in GFR. The nephrologists are prescribing him a 100grams of protein per day diet which is of course very skewed towards carbs while the diabetologist are prescribing an high protein low carb diet. I joked with the… Read more »

Axel F Sigurdsson
Axel F Sigurdsson
4 years ago

Thanks for the comment Robert
I agree with you completely. It is often very difficult to translate the results of clinical trials into real life patients. Maybe this patient would do well on a DASH or Mediterranean type diet, I’m not sure. It depends on the situation of course, whether he’s overweight/obese and what his preferences are.
I think your comment emphasises that dietary recommendations often have to be tailored to the patient’s needs, just like so many other therapies in clinical medicine.

bob_johnston
bob_johnston
4 years ago

The diabetologist isn’t prescribing a proper low carb (high fat) diet if he’s wanting this diabetic patient to be on a high protein diet. Type II diabetes is a condition of very high insulin resistance, you aren’t going to cure it or even stop it from worsening with a diet that doesn’t address the high insulin levels. Calling a diet simply low carb is misleading, a true low carb diet is low carb, moderate protein and high fat. People forget that protein that isn’t used for muscle building or body maintenance will be converted to glucose and is therefore insulinogenic… Read more »

Nigel Kinbrum
4 years ago
Reply to  bob_johnston

I used to be insulin resistant. I’m not, now. I reversed it, ‘cos I’m clever that way. All of the factors that can cause insulin resistance and what to do about them is detailed in my blog (link in Disqus profile). Find the label “Insulin Resistance” and click on it. I can eat a varied diet based on whole, minimally-refined animal & vegetable produce, including legumes, Basmati rice (I don’t eat wheat), roots, tubers & whole fruits. I can even eat occasional carby treats. Meanwhile, you have to spend the rest of your life on a restricted diet. You won’t… Read more »

Will
Will
4 years ago

I must admit I’m perpetually confused by the advice on diabetes or other chronic issues such as weight loss. I’ve read great success stories by Dr’s like Joel Fuhrman, Neil Barnard and the very high carb crowd and how they cure type 2 D in their patients. along with cholesterol, hypertension, and weight issues. And then I read about ow low carb can sometimes do the same. I’ll tell you upfront, my bias is to sit with the high carb crowd only because of n=1 experiments on myself. I am quote physically active and low carb eating styles always leave… Read more »

Axel F Sigurdsson
Axel F Sigurdsson
4 years ago
Reply to  Will

Thanks Will I saw the BBC documentary as well and found it misleading in many ways. Doing a trial on two persons is not very scientific. There is a lot of evidence for the usefulness of low carb diets in the world of sport for example. In fact I’ve also seen a number of people who feel exhausted and tired while restricting carbs. We are all different and our bodies react differently to different diets. People have to experiment and find the method that suits them. Although I believe carbohydrate restriction is often useful in metabolic syndrome and when insulin… Read more »

mbuster
mbuster
4 years ago
Reply to  Will

Will, First, I don’t believe in a Sugar Fairy and there is no CURE for diabetes. I would like to see the high carb doctors provide some verified data that their recommendations can even offer BG control, I am referring to keeping it in a safe range. I am a type 2 and my n=1 of Barnard’s BS was a total failure, I couldn’t get my BG to stay in a safe range eating the high carbs recommended. If you don’t mind, please share your n=1 results of high carb eating. What you ate, BG before the meal, BG one,… Read more »

bob_johnston
bob_johnston
4 years ago
Reply to  mbuster

When someone is a Type II diabetic what it really means is that they have severe insulin resistance. Insulin resistance is indeed reversible, it happens all the time. Now oftentimes a severly insulin resistant person has been that way for so long that a low carb, moderate protein, high fat diet isn’t totally effective and in that situation employing an intermittent fasting protocol seems to help tremendously. It might be informative to look up Dr. Jason Fung’s blog and check it out. Also I agree with your macronutrient ratios. So many people think a low carb diet is a high… Read more »

tannngl
tannngl
4 years ago

This was something we were taught in nursing back in 1964. Control of CHO intake is basic in ALL types of diabetes.

It amazes me how medical science can forget truths!

bob_johnston
bob_johnston
4 years ago
Reply to  tannngl

Nobody makes any money by limiting carbohydrates.

bob_johnston
bob_johnston
4 years ago

Why not see what diabetics who are successful in managing their blood sugars are eating?

On facebook the American Diabetes Association just asked how people are managing their blood sugar. The comments are hilarious and predictable in that the people who are enjoying success are doing the exact opposite of what the ADA recommends. The people having success are using a high fat, low carb, moderate protein diet.

https://www.facebook.com/AmericanDiabetesAssociation/posts/10153140618374033?fref=nf&pnref=story

Nigel Kinbrum
4 years ago
Reply to  bob_johnston

Sadly, links to Facebook posts don’t constitute evidence. Try PubMed (or better still, just give up posting pseudoscientific clap-trap on science blog comment sections).

Guðmundur F. Jóhannsson
Guðmundur F. Jóhannsson
4 years ago

These are my 2 cents on the matter: “Interestingly, empagliflozin may induce weight loss, lower blood pressure, reduce arterial stiffness and visceral obesity. All these effects may potentially explain why the drug is beneficial for patients with type 2 diabetes and cardiovascular disease. So, possibly, the reason the drug works has nothing to do with blood sugar whatsoever.” Coincidentally, all of these factors mentioned are downstream effects of insulin resistance/hyperinsulinemia. As chronically elevated insulin levels induce insulin resistance creating a vicious cycle, it makes sense that breaking that cycle by lowering s-glucose will result in improvement in all of the… Read more »

Axel F Sigurdsson
Axel F Sigurdsson
4 years ago

Thanks Guðmundur Your point is well taken. Like you, I’m not ready to exclude the possibility that the effect of body weight, blood pressure, vascular tone and visceral obesity are all secondary to less insulin resistance caused by lowering of blood glucose. With regards to the subgroup analysis I want to clarify that they are based on baseline data. Thus, in the group that had glycated hemoglobin 8.5% at baseline. Consequently, we would have to assume that the treatment effect was stronger among those with less insulin resistance compared to those with more insulin resistance at baseline. But again, in… Read more »

Kjartan
Kjartan
4 years ago

Hi guys. Do you think the levels of insulin secreted is reduced by this drug? I mean if you take a bite of a muffin and it gets all the way to your gut, and gets digested into glucose particles, shouldn’t the insulin response be the same (just thinking of the mechanism of the inkretins). I am just wondering if we do not see a big difference for those with severe insulin resistance, we are not treating the cause, which might be fat accumulation in the pancreas blocking the function of the beta cells, which you need to burn off.

Axel F Sigurdsson
Axel F Sigurdsson
4 years ago
Reply to  Kjartan

Kjartan.
I would assume there is reduced insulin secretion, secondary to lowering of blood glucose by the drug.
And of course it is possible that those with higher baseline HbA1c might also have more severe diabetes and could suffer from diminished insulin production together with insulin resistance. However, don’t you think they still should benefit from the glucose lowering effect of the drug?
But again, subanalyses of this kind have to be interpreted carefully.

wdinner
wdinner
4 years ago

Axel

Can’t help but thinking about my shirt maker. During WWII he suffered an accident in Borneo and became a diabetic with just a trace of insulin production. When he came home in ’46 his doctor told him you can take insulin or give up carbs. He gave up carbs eating meat, cheeses, and non-starchy vegies and lived to 88. I guess they understood how carbs worked back then.

Christine Gatzek Ruch
Christine Gatzek Ruch
4 years ago

A little late joining this discussion but it fits exactly with the topic of this presentation. Watch it and you will be amazed. He spoke a lot more about this in a seminar given by the Institute for Brain Potential.
https://www.bing.com/videos/search?q=david+diamond+phd+youtube&view=detail&mid=040BD3D2EC7FE8AD35BD040BD3D2EC7FE8AD35BD&FORM=VIRE

eve
eve
4 years ago

A TRUE LIFE TESTIMONY OF HOW I GOT CURED FROM DIABETES 2 VIRUS[with Herbal Traditional medicine] Hello My Name is Mary,I am Out here to give my testimony about a Herbalist doctor called Oyedepo who helped me in my life. I was infected with DIABETES VIRUS in 2013, i went to many hospitals for cure but there was no solution, so I was thinking how can I get a solution out so that my body can be okay. One day I was in the river side thinking where I can go to get solution. so a lady walked to me… Read more »

John sweet
John sweet
4 years ago

God bless Doctor Arthur moon for helping me cure my diabetes type 2. Brethren, i have suffered diabetes for a long period of time, i have tried so many remedy, but known seems to work. But i had contact with a herbal doctor who i saw so many people testifying on how they were all cured of their various disease and viruses by this doctor. So i explained my entire problem to him, and he promised to cure me. So i gave him all benefit of doubt, and behold he prepared the herbal mixture, and send it to me in… Read more »

Samaira Khatri
Samaira Khatri
3 years ago

Diabetes is a medical condition in which sugar, or glucose, levels build up in your bloodstream. There’s not enough insulin to move the sugar into your cells, which are where the sugar is used for energy. This causes your body to rely on alternative energy sources in your tissues, muscles, and organs.

This is a chain reaction that can cause a variety of symptoms. Type 2 diabetes can develop slowly. The symptoms may be mild and easy to dismiss at first.

To know more details about Diabetes visit this website:

https://www.freedoctorhelpline.com/diabetes/

benson lorenzo
benson lorenzo
3 years ago

Hi everyone, there is good news, a perfect and great one. My daughter of 17years who has suffered of HPV for 2 and half years has been cure by a Herbal doctor called Dr. buba who uses herbal and traditional medicine to cure people. I have spent so much on my daughter’s health paying hospital bills for years but no improvement. A friend told me about this herbal man who cure people with herbal medicine. he cures all sickness, diseases, viruses, and infections with his different herbal curing medicine. The result that declares my daughter Janet healed was from a… Read more »

crystal grham
crystal grham
2 years ago

God bless Dr.astogo for his marvelous work in my life, I was suffering for Diabetes since 2012 and I was taking my medications and i wasn’t satisfied i needed to get the Diabetes out of my body, I searched about some possible cure for Diabetes and i saw a comment about Dr. astogo, how he cured a woman with his herbal medicine, I contacted him and he guided me. I asked for solutions, he started the remedy for my health, he sent me the medicine through UPS SPEED POST. I took the medicine as prescribed by him and 14 days… Read more »

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