K. Bernstein, M.D., F.A.C.E., F.A.C.N., FCCWS, Shares His Ideas on Why There Was an Increase in CV Incidents and How the Intensive Treatment Regimen

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Diabetes Issues

Author: Dr. K. Bernstein Last Updated: Feb 16, 2008 - 6:15:55 PM

K. Bernstein, M.D., F.A.C.E., F.A.C.N., FCCWS, Shares His Ideas on Why

There Was an Increase in CV Incidents and How the Intensive Treatment Regimen

That Was Used May be the Culprit.

By Dr. K. Bernstein

Feb 16, 2008 - 6:15:27 PM

The ACCORD Study

(HealthNewsDigest.com) - Dr. K. Bernstein: The question is really, was

the claim made by the NIH that lowering blood sugar actually increased the

risk of death, a valid claim and if not, what was really going on?

Well, what I maintain is that the problem was in the treatment, not in the fact

that blood sugars were lowered. When this study was started, the ADA very

clearly mandated 60% to 65% dietary carbohydrate for diabetics. This high

carbohydrate diet forced the use of industrial doses of insulin, large doses

of sulfonylurea drugs and very possibly at the very least a hazard for

hypoglycemia; and a great likelihood of rollercoaster blood sugars as we usually

see in diabetics who are put on a high carbohydrate diet. So it looks like the

likely high carbohydrate diet was at the core of the problem. Now, aside

from the impossibility of real blood sugar control and indeed, although the

Colata article in the New York Times claims that the blood sugars were

very low. They weren't. They did not get below 6% on the A1C.

Six percent corresponds to an average blood sugar of 140 mg/dL. So the blood

sugars were still quite high. What hazards were introduced?

Well, first of all, we know from a number of studies that high carbohydrate

diets tend to increase rather than reduce cardiac risk factors. But in this

case, probably much more significant was the likelihood of weight gain. We use

low carbohydrate diets to reduce weight. So if you're going to give them

high carbohydrate diets and large doses of insulin to off set the resulting high

blood sugars, you're going to be building fat. And doing that to someone

who is already at high cardiac risk is just adding to their burden, probably

adding tremendously. In addition, there's been a lot written about the adverse

effects of high serum insulin levels, principally, on the vasculature. For

example, high serum insulin levels increase vascular leakage, cause pathologic

proliferation of the vascular endothelium, arterial stiffening, and

hypertension. In addition, the obesity also exacerbates hypertension. So if

you're

making people fatter, you're making their hypertension worse.

On the other hand, there have been articles pointing out that for insulin

deficient individuals, if you put them on insulin, you facilitate vascular

repair.

So there's a balance. Small physiologic blood levels of insulin help the

vasculature whereas these industrial blood levels of insulin are harmful for the

vasculature. So simultaneously, you're increasing hypertension, you're making

them fat and you're causing vascular damage in a number of different ways

just from the high carbohydrate and the high insulin.

So the conclusion that the study should be terminated perhaps should have been

replaced with a revamping of the study so that the treatment would be changed

to mandate very low carbohydrate diets and physiologic instead of industrial

doses of insulin. One other point to remember is that high doses of insulin

combined with high carbohydrate cause the rollercoaster effect. If you take a

type 2 diabetic who already has cardiac disease, and you put them on the

rollercoaster blood sugars, up and down, and up and down, you're not doing his

heart any good.

A similar situation occurred in the DCCT trial in the intensive arm, more

hypoglycemia. I wrote an article that was published in the American Journal of

Medicine, after the DCCT. They were complaining that they had so much

hypoglycemia, even at A1C's of 6% and they didn't get below 6%, but approaching

6%

they got more and more severe hypos. I pointed out the laws of small numbers

wherein high carbohydrate plus high insulin causes unpredictable blood sugars.

Items missing in the NIH press release included, was there weight gain, what

sort of diet they were on, which medication and how much they were using. I'd

be very surprised if they were put on a low carbohydrate diet. I�m willing to

bet that they were put on an ADA diet and it was probably very high in

carbohydrate.

I am assuming that they used high doses of insulin and sulfonylureas because

it's very hard to offset carbohydrate with metformin, Actos or Avandia; whereas

sulfonylureas, are almost as potent as insulin but they work by boosting your

insulin levels. If you can make insulin and you get a sulfonylurea, you'll

have very high serum insulin levels which can cause you to gain weight.

From Interview with www.DiabetesinControl.com.

Dr. K. Bernstein is the Author of Diabetes Solution, www.diabetes911.net