Cerebralchatter
Posts: 2
Joined: 4/6/2010
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LafayetteLady,
Well, throwing terms like "irresponsible" around is, in itself, irresponsible. I never mentioned medications one way or the other. Everything you wrote about my supposed attitude to medications was nothing more than you putting words into my mouth, magicking a position out of thin air and then condemning me as irresponsible for taking a stance you created and which I never espoused. If we wish to talk about irresponsible then that's a pretty good definition of irresponsible behaviour.
Medications do, of course, have a role to play. That doesn't change the fact that in the long-term diet and exercise which results in weight loss sufficient to bring HbA1c levels and fasting and random blood glucose levels to within the normal range IS superior to taking medications which achieve the same effect in the long term. The key being in the long term. Obviously, in the short term medications have a role to play in ensuring control while diet and exercise take their toll.
As to people who cannot be controlled through diet and exercise. Well, obviously control on medications is superior in terms of morbidity, mortality and overall outcome than poor control without medication.
On the whole though control through diet and exercise such that weight is lost and blood sugar remains within normal limits ( thus allowing the removal of the diagnosis of DM Type 2 ) is superior through control relying on medications. The reason for this is multifactorial and includes, but is not limited to:
1. Greater responsiveness of the human body to food intake in terms of sugar regulation than tablets taken on a schedule.
2. The fact that weight loss also reduces the risk of many other cardiovascular illnesses, the risk of non-central sleep apnoea and also the risk of many forms of cancer all of which are independently related to weight.
3. Differences in metabolism which occur through exercise which are independent of actual weight level.
You may, of course, choose to hold different views and I would not disagree with your right to do so. But there is a certain responsibility involved in giving advice to others. I'm only speaking up because by giving non-evidence based advice to others you may harm their outcome and not just your own.
Here's some good summary article references for those interested:
Damon, S., M. Schatzer, et al. (2011). "Nutrition and diabetes mellitus: an overview of the current evidence." Wien Med Wochenschr.
Overwhelming evidence exists supporting the benefit of lifestyle and nutritional interventions to prevent or delay type 2 and gestational diabetes and improve glycemic control and co-morbidities in patients of all sub-types of diabetes mellitus. Therefore, nutritional therapy is an indispensable and fundamental treatment component, which has to be based on evidence-based recommendations, adapted for dietary intake and medication, and periodically adapted according to diagnosis and individual course of illness. This overview is based on the currently valid evidence-based nutritional recommendations of the European and American Diabetes Associations for the management of diabetes mellitus. It describes the quality and quantity of beneficial macronutrient (carbohydrates, fat, and protein) and micronutrient intake, alcohol consumption, and food groups. Moreover, the evidence for supplements and functional foods is summarized and the role of body weight and different weight loss diets are discussed.
The next article shows the benefits in terms of reduction in medications necessary if the patient loses weight and exercises - and reduced meds not only mean financial savings for the patient but also reduced side effects.
Anderson, J. W. and M. A. Jhaveri (2010). "Reductions in medications with substantial weight loss with behavioral intervention." Curr Clin Pharmacol 5(4): 232-238.
Medical costs of obesity in the United States exceed $147 billion annually with medication costs making a sizable contribution. We examined medication costs associated with substantial weight losses in an intensive behavioral weight loss program. Inclusion criteria were medication use for obesity co-morbidities: hypertension, diabetes, dyslipidemia, degenerative joint disease, or gastroesophageal reflux disease. Group A, 83 obese patients on medications completed 8 weeks of classes, lost 19 kg in 20 weeks. Group B, 100 severely obese patients, lost 59 kg in 45 weeks. Medications were discontinued: Group A, 18%; Group B, 64%. Mean numbers of medications decreased significantly for all co-morbidities. Mean numbers of daily medications, initial and final, respectively were: Group A, total, 3.0 +/- 0.2 (mean +/- SEM) and 1.7 +/- 0.2; Group B, total, 2.5 +/- 0.2 and 0.7 +/- 0.1. Monthly costs for all medications decreased significantly for all co-morbidities and were as follows: Group A, total, $249 +/- 25 and $153 +/- 19; Group B: total, $237 +/- 27 and $65 +/- 12. Medically supervised weight loss is very effective approach for improving cardiovascular risk factors and reducing medical costs.
Next is an article which points out the likelihood of having poorer HbA1c etc control the heavier the patient, which may require more insulin and other oral meds --- which often have the side-effect of increasing weight even farther, thus causing the diabetic spiral of poor control, more meds, more weight gain, leading to poorer control and a need for more meds which put on more weight. Obviously, if diet and exercise reduces the weight then you can get this diabetic spiral acting in the other direction and being a positive factor.
Mavian, A. A., S. Miller, et al. (2010). "Managing type 2 diabetes: balancing HbA1c and body weight." Postgrad Med 122(3): 106-117.
Most patients with type 2 diabetes present with comorbid overweight or obesity. Reaching and maintaining acceptable glycemic control is more difficult in overweight and obese patients, and these conditions are associated with increased risk for cardiovascular and other diseases. Glycemic management for these patients is complicated by the fact that insulin and many of the oral medications available to treat type 2 diabetes produce additional weight gain. However, an increasing number of therapeutic options are available that are weight neutral or lead to weight loss in addition to their glycemic benefits. This article evaluates the evidence from clinical trials regarding the relative glycemic benefits, measured in terms of glycated hemoglobin change, versus the impact on body weight of each medication currently approved for type 2 diabetes. In general, the sulfonylureas, thiazolidinediones, and D-phenylalanine derivatives have been shown to promote weight gain. The dipeptidyl peptidase-4 inhibitors are weight neutral, while the biguanides, incretin mimetics, and amylin mimetics promote weight loss. Trials examining the glycemic benefits of the weight loss agents orlistat and sibutramine are also examined. Awareness of this evidence base can be used to inform medication selection in support of weight management goals for patients with type 2 diabetes.
Lastly, while I wouldn't suggest Roux-en-Y bypass without consultation with a surgeon this study shows that following bypass AND cessation of ALL diabetes meds 100% of the patients in this study were euglycemic ( in other words, no longer had diabetes type 2 ) 3 months after their surgery. This in spite of the fact that they were on no meds. Functionally this means that the ONLY reason they could have stopped having diabetes was due to the weight loss caused by the surgery. Obviously there is other stuff about operative risk in this paper but the findings as regards weight loss and its impact on HbA1c and glycaemic control and need for meds are pretty stark.
Shah, S. S., J. S. Todkar, et al. (2010). "Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m(2)." Surg Obes Relat Dis 6(4): 332-338.
BACKGROUND: Roux-en-Y gastric bypass (RYGB) benefits patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m(2); however, its effectiveness in patients with T2DM and a BMI <35 kg/m(2) is unclear. Asian Indians have a high risk of T2DM and cardiovascular disease at relatively low BMI levels. We examined the safety and efficacy of RYGB in Asian Indian patients with T2DM and a BMI of 22-35 kg/m(2) in a tertiary care medical center. METHODS: A total of 15 consecutive patients with T2DM and a BMI of 22-35 kg/m(2) underwent RYGB. The data were prospectively collected before surgery and at 1, 3, 6, and 9 months postoperatively. RESULTS: Of the 15 patients, 8 were men and 7 were women (age 45.6 +/- 12 years). Their preoperative characteristics were BMI 28.9 +/- 4.0 kg/m(2), body weight 78.7 +/- 12.5 kg, waist circumference 100.2 +/- 6.8 cm, and duration of T2DM 8.7 +/- 5.3 years. At baseline, 80% of subjects required insulin, and 20% controlled their T2DM with oral hypoglycemic medication. The BMI decreased postoperatively by 20%, from 28.9 +/- 4.0 kg/m(2) to 23.0 +/- 3.6 kg/m(2) (P <.001). All antidiabetic medications were discontinued by 1 month after surgery in 80% of the subjects. At 3 months and thereafter, 100% were euglycemic and no longer required diabetes medication. The fasting blood glucose level decreased from 233 +/- 87 mg/dL to 89 +/- 12 mg/dL (P <.001), and the hemoglobin A1c decreased from 10.1% +/- 2.0% to 6.1% +/- 0.6% (P <.001). Their waist circumference, presence of dyslipidemia, and hypertension improved significantly. The predicted 10-year cardiovascular disease risk (calculated using the United Kingdom Prospective Diabetes Study equations) decreased substantially for fatal and nonfatal coronary heart disease and stroke. No mortality, major surgical morbidity, or excessive weight loss occurred. CONCLUSION: RYGB safely and effectively eliminated T2DM in Asian Indians with a BMI <35 kg/m(2). Larger, longer term studies are needed to confirm this benefit.
So, as I said, there's a clear evidence base supporting exercise and diet to lose weight as being the safest, most effective treatment for DM Type 2. Sure, in the short term one can take meds while the diet and exercise take hold but those meds have side effects and can be eliminated in most patients with diet and exercise. YOu can, of course, choose to do something different with your life but to call evidence-based medicine "irresponsible" is irresponsible in its own right.
With all of that said, I am ONLY replying because I think in a public forum there is an onus to provide evidence-based advice. You are free to do whatever you want with your life and I most assuredly hope that whatever approach you takes works out well for you.
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