The companies and clinicians that claim they can reverse diabetes point to reductions in weight, sugar levels, insulin resistance, inflammation, triglycerides, blood pressure, and the use of diabetes medications other than metformin. By severely restricting carbohydrate intake, medication requirements drop, and the fasting glucose falls below 126, which is the number required to diagnose diabetes. So, in that sense, they have reversed diabetes. But they have not prevented death, heart attack, and stroke. Most patients with diabetes die or become disabled because of vascular disease. Reducing heart attack, stroke, and other hard complications is the point of treating diabetes—not merely reducing the blood sugar.
Restricting carb intake in diabetes is very important. This idea makes perfect sense. So did the design of the ACCORD trial. My team had 180 patients in that landmark trial, and we were enthusiastic about reducing the sugar level to near normal. The study also examined the benefits of cholesterol and blood pressure control. The lead investigators believed that lowering the sugar to near normal would reduce deaths, heart attacks, and strokes. We were completely shocked when more people died in the intensive glucose lowering group and the trial had to be stopped early. With intensive glucose-lowering treatment 257 patients died, compared with 203 in the standard therapy. That is a 22% increase in all-cause mortality.
Lowering the sugar failed to reduce death, stroke, and heart attack. It made sense, but it did not work. High blood pressure is the most common additional risk factor in type 2 diabetes. Likewise, in the landmark ACCORD trial an intensive BP control strategy to achieve a top number on the blood pressure less than 120 did not significantly reduce death, nonfatal heart attack, and nonfatal stroke compared with a standard goal of less than140. It made sense but it did not work. In response, the guidelines relaxed the targets for blood pressure and blood sugar. That was a mistake. Lowering blood sugar and blood pressure to aggressive goals is extremely important. The way that you lower them is even more important. These shocking results resulted in regulations that require proof that any new treatment for type 2 diabetes reduces the risk of death, heart attack, and stroke. Those are the hard outcomes that matter. Risk factor reductions are intermediate outcomes and I have just explained that they don’t always lead to a reduction in hard outcomes.
There is also a long-term trial of diet in type 2 diabetes. The Look Ahead trial was also a landmark trial sponsored by the NIH. It failed. Patients lost weight, but there was no reduction in heart attack and stroke. Things that make sense often don’t work.
That would all be awful if there was no alternative that does work, but that is not the case. There is a set of interventions for diabetes that includes diet, exercise, aggressive risk factor targets, and treatment with specific medications that makes a huge difference in heart attack, stroke, and death rates. It is called optimal medical therapy (OMT). Patients on OMT for type 2 diabetes with chronic kidney disease have one fourth as many heart attacks, one fifth as many strokes and one sixth as many patients go on dialysis compared with those in usual care—the care that most of us receive. Check out the slide below for all the benefits of OMT compared with usual care. There is 21 years of followup for this study.
OMT is it. There is no other intervention for diabetes that produces these kinds of outcomes. I have broad experience with this kind of care and have been working with Vestra Health for 5 years. They produce OMT for patients with diabetes and other cardiometabolic conditions. Patients seen in their clinic cost half as much as patients seen in the broader community. They are in the hospital one fifth as often and in the ER one third as often. I think that means we are replicating the results of this diabetes trial in the community by consistently producing OMT.
How can you possibly make sense of this information? If treating diabetes is all about lowering risk factors you can’t. But it is not all about risk factors. Some interventions for diabetes are much more powerful than others in preventing the terrible complications of diabetes. Jardiance is one of those medications. If you achieve the same sugar level with Jardiance as you do with other interventions, the patients on Jardiance will be in the hospital for heart failure 30% less. Their chronic kidney disease will progress thirty percent slower.
Jardiance is more protective than other ways of achieving the same blood sugar because, like fasting, it activates the master metabolic survival switch AMPK and that protects every cell and organ in the body. The leading heart failure specialist Milton Packer said it this way: “However, regardless of how their actions are envisioned, it is now critical for physicians to reconceptualize SGLT2 inhibitors (like Jardiance) as organ-protective agents rather than glucose-lowering drugs. The antihyperglycemic (glucose lowering) action of these drugs represents a tiny fraction of their broad portfolio of effects, which (when fully exercised) cause an adaptive reprogramming of stressed cells in a manner that promotes homeostasis and survival.” It is no longer only about lowering the sugar. It is about protecting cells and organs.
Optimal medical therapy is the only way to reduce death, heart attack and stroke in type 2 diabetes. OMT is a product. Advanced primary care teams can consistently produce that product and these outcomes by using protocols, patient engagement tools, population health tools, along with robust clinical and financial analytics. That systematic approach can be easily scaled and until we begin, more patients will die and have heart attacks and strokes. It is just that simple.
Here's a thought... instead of pumping people full of drugs that promote the excretion of blood sugar, how about just bot eating foods that raise blood sugar?
You said it here yourself - "Jardiance is more protective than other ways of achieving the same blood sugar because, like fasting, it activates the master metabolic survival switch AMPK..."
It sounds like you're saying that fasting is as good as or better than Jardiance at lowering blood sugar so why take a drug that will expose you to presumably nasty side effects as well?
High blood sugar and insulin resistance occurs because on the Standard American Diet a person's cells are filled to their limit with glycogen and can't accept anymore. That's why drugs like Metformin and injected insulin are failures at preventing heart attacks and strokes... they simply force the overwhelmed cells to accept even more sugar where it causes even more damage. In fact, serum blood sugar levels alone are a poor marker for health, you can have normal blood sugar and still be insulin resistant. A much better test is a test that accounts for insulin as well, such as HOMA-IR.
HCPs should be telling people with diabetes to stop eating foods filled with seed oils, sugar and foods that metabolize into sugar (carbs). If they did that nobody would need Metformin, insulin or even Jardiance.
This is amazing information - including all the things that DO NOT WORK - and then the protocol THAT DOES WORK. Great work!!