All too many patients arrived on the doorstep of Dr.Atkins’office only after they had received a diagnosis of diabetes. When you’re told you have a serious disease, it’s usually pretty terrifying. And that fear often drives people to consider alternatives to what their mainstream doctors advise. That’s where Dr. Atkins usually came in. Perhaps the patient had heard a success story about someone who had used his approach,or maybe they had read one of his books and felt it was talking to them. Very often, they felt that medicine had failed them, and they just wanted to get their health back.
Dr. Atkins had two goals for his patients with diabetes. First, by teaching these patients the Atkins Blood Sugar Control Program (ABSCP), he helped them get their blood sugar under control. Second, he worked with them to cut back on the amount of medication they took each day. Success comes when a patient has good blood sugar numbers and needs no drugs at all, or is down to the least possible number of drugs taken in the smallest possible doses. Most of Dr. Atkins’ patients were able to achieve that success within a year. Many were also well along to achieving their weight-loss goals.
TRACKING YOUR BLOOD SUGAR
If you have diabetes, your primary goal is to bring your fasting blood sugar below 126 mg/dL—and preferably to 100 mg/dL or less. Once you start following the ABSCP, this may happen with surprising speed, but for many people some time may be required to return the insulin/glucose metabolism to normal functioning. After all, it took a long time to get to this stage of diabetes. You can’t expect to reverse years of high blood sugar overnight.
You’ll monitor your progress by using a home blood sugar meter.A number of high-quality meters are now available at pharmacies or medical supply stores.Work with your doctor or pharmacist to choose the one that’s right for you and learn how to use it correctly.
When you start following the ABSCP, your meter becomes a useful tool for monitoring your progress. Check your blood sugar first thing in the morning before eating or drinking anything other than water and keep a record of the numbers. (If you’re taking insulin, you’ll probably need to test your blood sugar several times a day—first thing in the morning, just before meals, and at bedtime.) As you change your way of eating and start exercising more, you should see your blood sugar numbers improve.Once you’ve got your blood sugar normalized and your glycated hemoglobin (A1C) number is coming down (see page 78), you don’t need to check your blood sugar quite so often.Every other day is fine at that point,unless your doctor instructs you otherwise. As your blood sugar continues to improve, you can move to checking it just twice a week. Continue to keep a record—we think you’ll be very pleased with the results.
Important note: Talk to your doctor about what to do if your blood sugar goes up to a higher level or drops to a lower level than is usual for you.You will probably be told to call him or her if your blood sugar rises beyond a particular level—be sure you and your doctor are in agreement as to what that level should be.Illness,infection,surgery, or high levels of stress can make your blood sugar go higher than is normal for you. Call your physician if you don’t feel well or have new symptoms that you can’t explain.
THE A1C TEST
A blood test called the glycated hemoglobin (A1C) is extremely important for tracking your blood sugar over time. This test measures the amount of sugar that has become bound to a protein molecule called hemoglobin, which is found in your red blood cells. The A1C is sometimes called the blood test with a memory, because it gives a pretty good picture of what your blood sugar has been doing over a three-month period.Once a person has been diagnosed with diabetes, the A1C is the standard method used to assess “glycemic control,” or how close your blood sugars are to the normal range. A normal A1C result in a healthy person without diabetes would be in the 4 to 6 percent range.When diabetes is first diagnosed, a person’s A1C will probably be above that range, possibly even as high as 15 percent. The higher the A1C, the greater the risk for diabetes-related complications such as kidney disease, eye disease, and nerve damage.
The standard therapeutic goal for people with diabetes, as set by the American Diabetes Association (ADA) and other professional organizations,is an A1C of 7 percent or less.Dr.Atkins’goal for his patients was 6 percent or less. Almost all his patients achieved significantly lower A1C numbers within a few months of controlling their carbohydrates and exercising more. His recommendation was to have the A1C test done every three months until good control, meaning A1C below 7, was achieved, then two or three times per year unless there is weight gain or a worsening of blood sugar control.
THE SCOOP ON ANTIDIABETIC DRUGS
If you are diagnosed with Type 2 diabetes, in addition to the high-carb ADA diet, your doctor will almost certainly put you on one or more prescription drugs to control your blood sugar. You may also be prescribed drugs to control your blood pressure and blood lipids.
Dr. Atkins believed that drugs for treating blood sugar abnormalities and diabetes should be avoided if at all possible. If your diabetes is far advanced, however, drugs may indeed be necessary. In serious cases, he had no hesitation in prescribing drugs, but there were only two blood sugar medications he used: metformin (Glucophage) and, if necessary, insulin.
Why did Dr. Atkins avoid all the other drugs that are often prescribed for controlling blood sugar? Let us explain. Some of the drugs prescribed for Type 2 diabetes stimulate the pancreas to release more insulin; others make your cells more sensitive to insulin. The fact is this: No drug works as well as controlling your carbs and getting more exercise.And most drugs for diabetes end up actually making your situation worse. Why? Because with the exception of metformin, every drug for diabetes makes it almost impossible to lose weight and may well make you gain weight.In addition,some diabetes drugs make you retain water, which can only worsen blood pressure (creating the scenario for, yes, more medications). Dr. Atkins felt that almost all diabetes drugs get you into a futile cycle that leads to larger doses of more drugs, rather than actually improving your health.
As a result, the only drug (other than insulin when necessary) Dr. Atkins usually prescribed for blood sugar abnormalities was metformin (Glucophage).This is the only diabetes drug that doesn’t cause weight gain. Metformin is helpful for people who have dangerously high blood sugar that needs to be lowered quickly—more quickly than dietary change and exercise alone can accomplish. It’s also helpful for those who are very metabolically resistant to the effects of dietary change and exercise. For these patients, taking metformin can be very helpful, and Dr.Atkins didn’t hesitate to prescribe it—along with the Atkins Blood Sugar Control Program, of course. As the combination starts to work, the metformin dose can often be gradually reduced and eventually stopped. There are, of course, some who may need to remain on it indefinitely.
Often, Dr. Atkins’ patients came to him already taking two oral diabetes drugs—usually metformin in combination with another drug such as glyburide (Glucovance), which is an insulin-stimulating drug. In most instances, he would switch the patient to metformin alone.As the ABSCP begins to lower blood sugar, the insulin-stimulating drugs can lower blood sugar too much, causing a dangerous hypoglycemic reaction. An important precaution: If you take any of these medications and are about to start following the ABSCP,speak with your doctor first. You need to plan a strategy for lowering your medications as your new dietary approach starts to work. It is, of course, still necessary for you to continue to monitor blood sugar readings at home.
THE INSULIN DECISION
If you have progressed to stage 6 of Type 2 diabetes, the beta cells in your pancreas are now producing less insulin than you need. In fact, after years of a high-carb diet and high blood sugar, your beta cells may not be making much insulin at all. You need insulin to survive, however, so at this point you will probably have to start administering this powerful hormone to yourself, often several times a day. Your insulin dose, the type of insulin you use, and when you administer it depend on a number of factors. Every person who needs to use insulin is different,and you’ll have to work closely with your doctor to design an individualized program that works for you.
Because taking insulin can cause dangerous episodes of hypoglycemia, and because it almost invariably causes weight gain, Dr. Atkins always aimed to help patients who were using it to discontinue it or reduce their dose. Fortunately, many of his patients were able to do exactly that by following the ABSCP. In fact, there were situations where the patient was able to discontinue the use of insulin immediately. (See the case of Glenda Carter on page 151 for an example of someone who was able to stop using insulin as a result of the ABSCP.) Let us say at once, however, that this is not always the case. Stopping or changing your dose of insulin must be handled on an individual basis, working with your doctor and closely monitoring your blood sugar. This is a complex process that needs to be handled carefully— never try to adjust your insulin dosage without discussion with your physician.
When you start controlling your carbs and bringing your blood sugar under control, you break a vicious, long-standing cycle in your body. When your blood sugar finally stabilizes, the beta cells in your pancreas may very well be able to resume their normal response. Insulin production will often improve—in fact, it may even return to normal levels.
WHAT YOUR FUTURE HOLDS
Often when people are first diagnosed with Type 2 diabetes, they go home with dark and gloomy images of a lifetime administration of insulin, wounds that won’t heal, or even amputations. Those images are worst-case scenarios, but they are real possibilities—especially if you continue to eat in the way that led you to gain weight and become diabetic in the first place. In case your blood sugar has been too high and your mind foggy, let us remind you: The diet that brought you here is the one that includes large amounts of nutrient-empty carbohydrates.
Continuing on that diet could even cause your doctor to prescribe insulin unnecessarily. In our experience, many people are put on insulin even when they continue to produce high amounts of it themselves. That’s because their blood sugar is so high that their doctors assume they are no longer producing enough insulin. One reason blood sugar might be so high is that their diets may be chock-full of the high-carb foods that cause blood sugar to skyrocket.
Unfortunately, most doctors simply assume that their patient needs insulin without investigating any further (e.g., performing the two- hour postprandial test discussed in Chapter 6).They prescribe a powerful hormone that you may have to take for the rest of your life without any real understanding of whether you truly need it. Dr. Atkins could never understand why the postprandial test is so often skipped.When- ever he considered prescribing insulin for a patient, he would order a two-hour postprandial test that let him compare the fasting blood sugar and fasting insulin levels with the levels reached two hours after a high-carb meal. This is how he would find out how much insulin was being produced and what the patient’s glucose response was.
One of the downsides of prescribing the powerful hormone insulin is that in the absence of carbohydrate restriction it will often cause weight gain.With the exception of metformin, the other drugs used to stimulate insulin production and increase insulin sensitivity are also problematic when it comes to weight management, which makes every other aspect of managing diabetes more difficult. Remember Larry H., a patient we discussed back in Chapter 3? When Dr. Atkins first saw Larry, he had been taking glipizide (Glucotrol) for a year. Not surprisingly, he had gained weight over that period and was now carrying 255 pounds on a five-foot-nine-inch frame. Aside from making him gain weight,the glipizide wasn’t doing much for Larry.His fasting blood sugar was just over 200 mg/dL and his glycated hemoglobin (A1C) was 7.3 percent. Dr. Atkins immediately switched Larry from glipizide to metformin. Within four weeks, he began losing weight and his fasting blood sugar was down to 130 mg/dL, a definite improvement, but Larry remains a work in progress.
Of course,some patients most certainly do need insulin and always will. In those cases, the ABSCP can still be very helpful. By controlling the carbohydrates in the diet, people who must take insulin can gain better control over their blood sugar, have a chance to decrease their insulin doses, manage their weight more successfully, and avoid the dangerous hypoglycemic episodes that plague so many diabetics who use insulin.
Your future doesn’t have to be a downward spiral of multiplying drugs, insulin administration, and poor health. Even if you have gone so far down the diabetes road that you must use insulin, it is still possible to slow or even halt the progression to more serious illness.
The next two chapters will discuss high blood pressure and heart disease—two very common complications of diabetes. But, as you’ll learn in later chapters, you have the power to limit the complications of diabetes and to optimize your health
COMMON DRUGS FOR TYPE 2 DIABETES
Although Dr. Atkins used very few of the following medications, we think it is important that you understand how they work and their potential side effects.
Drugs for treating Type 2 diabetes fall into these main groups:
S ULFONYLUREAS . These drugs stimulate your pancreas to release more insulin. They include chlorpropamide (Diabinase), tolazamide (Tolinase), glipizide (Glucotrol), tolbutamide (Orinase), glimepiride (Amaryl), glyburide (DiaBeta, Micronase), glibenclamide, and gliclazide.
Side effects include weight gain, fluid retention, and a slightly increased risk of a cardiac event such as a heart attack.
M EGLITINIDES . These drugs stimulate your beta cells to produce insulin. They include repaglinide (Prandin), nateglinide (Starlix), and mitiglinide.
Side effects include diarrhea, headache, and a slightly increased risk of a cardiac event such as a heart attack.
B IGUANIDES . The only drug now available in this group is metformin (Glucophage). Although the mechanism of action is not fully understood, metformin probably works by making your cells more sensitive to insulin and reducing glucose production in your liver. Metformin doesn’t cause weight gain or fluid retention.
Side effects include nausea, diarrhea, and a metallic taste in the mouth. (Our experience has been that most people can adjust to any gastrointestinal side effects by starting with a lower dose and gradually increasing to the prescribed amount.) People with heart failure or kidney disease should not take this drug.
T HIAZOLIDINEDIONES . Also known as TZDs or glitazones, these include rosiglitazone (Avandia) and pioglitazone (Actos). These drugs improve your sensitivity to insulin.They are usually prescribed in combination with other diabetes drugs.
Side effects include weight gain, fluid retention, anemia, and liver problems.These drugs can be very risky for people with heart failure.
C OMBINATION T HERAPY. The combination of metformin and glyburide (Glucovance) is often used to increase insulin sensitivity and to help your pancreas release more insulin.
Side effects include diarrhea and hypoglycemia. I
NSULIN . If your diabetes has progressed and you can no longer produce much or any insulin, you may need to administer additional insulin. Insulin use is complex; miscalculated doses can lead to hypoglycemic episodes.If you are on insulin and using the ABSCP,it is essential that you plan ahead and work with your doctor to adjust your dosage as your blood sugar begins to stabilize naturally.
Side effects: Insulin usually causes weight gain.
WHAT’S YOUR DIABETES IQ?
The more you know about managing diabetes, the easier it will be for you to follow the ABSCP and avoid complications.Check your diabetes knowledge with this quiz.
1. Call your doctor if:
2. Check your A1C knowledge:
3. Which of the following diabetes drugs don’t cause weight gain?
4. Insulin may be needed if:
Answers
d,True.3.b.4.d.c,False;b,False;1.c.2.a,True;