Is there a cure for diabetes? Is that cure rooted in what we eat? Find out in this week’s blog.
The plant-based diet is always a controversial issue. One viewer commented, “Do you follow Dr. John McDougall”?
I’ve seen Dr. John McDougall, including his lectures at the College of Lifestyle Medicine. I have friends, Michael Parkinson and Miriam Alexander, who helped found the College of Lifestyle Medicine.
Dr. McDougall said some sulfonylureas double the risk of death. He’s right. I’ve never written a script for a sulfonylurea and never will. They decrease blood sugar, and they can cause hypoglycemia (abnormally low levels of blood sugar).
There are a lot of people involved in the standards for endocrinology. They have debated and tried to take sulfonylureas out. They’ve been back and forth. There’s a move to put them back in.
Why give medications at all? Well, some patients need them. Unfortunately & incorrectly, Dr. McDougall assumes that metformin, DPP-4 inhibitors, and GLIP-1s inhibitors do the same thing that sulfonylureas do, so don’t give them. I’ll acknowledge that any medication has a side effect, although I don’t think they are the same.
Dr. McDougall points out how metformin and sulfonylureas are cheap and that there’s not a lot of drug money around them anymore. The National Institute of Aging is trying to develop a clinical trial called TAME (targeting aging with metformin). They had issues finding it, partly because it is so reasonable; many pharmacies like Walmart pharmacy are giving it out for free or zero copays. There is no drug money around metformin now.
There is drug money associated with some diabetic meds- big drug money.
Dr. McDougall’s main point is that lifestyle is the cure for diabetes; diet, not drugs; he states, “lose weight, drop the fat in your diet, and your diabetes will go away.”
I went for 30 years with a plant-based diet. I kept a BMI of about 21. A low-fat diet with plenty of exercise. I didn’t do as many high-intensity intervals and resistance training as I do now. I played basketball, ran marathons fairly regularly, half-marathons regularly, and even an ultra marathon.
The bottom line is that I had excellent exercise patterns- and I still developed insulin resistance. I have plenty of patients like that. You have patients who do all of this and still become insulin resistant. So, maybe losing weight & exercise are not enough.
Let’s talk about how The American College of Endocrinology standard. Here are a few things that they recommend:
Lifestyle optimization is essential. Even the standards guys get it- lifestyle, lifestyle, lifestyle. But lifestyle alone doesn’t work for all patients.
Weight loss. If you’re overweight and have type 2 diabetes, a lifestyle change is critical. There is no question that lifestyle is the most important intervention.
The AACE recommends an A1c target of 6.5. I disagree with that. I think that’s way too high. My target at PrevMed is 5.0 and below. A lot of people don’t reach that as they get into their 60s because of genetic and aging issues
The AACE recommends self-monitoring blood glucose. I agree. If you have a problem, how can you deal with it if you’re not measuring it?
The AACE recommends individualizing medications. The priority should be to minimize the risk of hypoglycemia. Sulfonylureas & insulin are dangerous in this area. Metformin. Glp1s, & SGLT2s are far safer. Dr. McDougall overgeneralizes in this critical area. He says all meds are wrong. No, sulfonylureas are bad. Sulfonylureas are bad because they have a significant risk of hypoglycemia. A much higher risk than metformin or pioglitazone for the orals. When you get into the injectables, there are different issues.
The AACE has several recommendations. They believe metformin is low risk. It’s a baseline for combination therapy when most people get up to 6.5-7s, and 8s will need combination therapy. I agree with that.
I’m just getting to them earlier. We’re intervening more quickly. We need to deal with blood pressure and lipids. I agree.
To summarize this debate: Lifestyle is vital. I get it. I’ve been preaching that gospel for 30-something years. Plus, I’ve lived it. I’ve never had a BMI of over 24.
We complain about the standards of people being too slow and too conservative. I would say the American College of Endocrinology is quiet and traditional. Hemoglobin a1c level is the recommendation that I say is too conservative. However, even they get it. Lifestyle is item number one; it’s item number two, it’s also even item number three.
How about the patient with a BMI of 21 who has been on a plant-based diet for decades and exercises well? However, they are still insulin resistant.
What do you tell them? Go low-carb, get your BMI down to the low 20s, and exercise. There are plenty of them. They increase by age 60- 50% of folks have significant insulin resistance. By age 65, it’s significantly over 75%. You will see lower numbers if you check the CDC.
Part of the reason is that the CDC uses hemoglobin a1c of 6.5 and 7 or above surveys.
Suppose you look at my patients- lifestyle is 1st, 2nd, and 3rd. Look at my patients’ YouTube videos. You’ll see the same thing. I’ve got tons of patients that have lost 20-30- 40 pounds.
If you look at the clinical trials, lifestyle has performed about three times more effectively than medications. But with the clinical trials, they’re talking about decreasing your BMI by 10% or more. Some people can’t accomplish it. Some people manage to perform it, but they still have insulin resistance. Therefore, sometimes lifestyle is not enough.
Why are we having all of this passionate debate? Am I saying, “doctor, where’s the disconnect here?” Are plant-based doctors like Khan, McDougall, Greger, and Bernard wrong? No, I’m not saying that. Here’s the issue: they’re covering the vast majority of the US population and what’s growing to be the world population. It is an obese, low exercise type group. That’s the problem. Any type of weight loss will help this group. But for most of us cutting carbs helps with both problems: weight loss AND insulin resistance.
The number is growing every day. Some aging people already have a low BMI on their plant-based diet. And every time they eat carbs, their glucose spikes. These people need to watch their carbs, not just their calories.
There is more than one cause of insulin resistance and diabetes type 2. In diabetes, the most common cause is aging. Genetics is another common cause. Weight is important. Macronutrients in your diet are essential. We’re finding out more and more. There’s still debate.
Please, let’s realize there’s a time and a place to be passionate. Let’s not throw each other under the bus, as we often do when we don’t realize that more than one perspective can be right. Often the issue is more complicated than we realize.