The Relationship Between Type 2 Diabetes Mellitus And Statin Therapy

Stanley Feld M.D. FACP, MACE

Readers have continuously reminded me that consumers are not smart enough to purchase the right kind of healthcare.

"Hello Dr. Feld,

What is your solution for patients who simply aren’t educated enough to make these decisions on their own? In “Redefining Healthcare” Michael Porter advocates a role for insurers to help in this regard and I’m wondering what your thoughts are given that the fastest growing demographic in America is poor, uneducated, and potentially (as a result) unhealthy folks."

I refuse to believe that consumers are too stupid to be educated if properly motivated.

I welcome insurance companies trying to educate consumers but they are doing it for their benefit and not the patients’ benefit. The education offered is not an extension of the physician’s care and will therefore be ineffective.

I respect the intelligence of all consumers. They will want to become educated consumers as soon as there is a financial benefit.

Any educational system built will have no effect on about 10% of the population. These people will be a burden to society.

The government and the healthcare insurance companies had their day trying to fix the healthcare system.

It is now the consumers’ turn to use their consumer power to fix the healthcare system. Consumers are starting to realize they need to be responsible for their care. They are also realizing they must control their healthcare dollars.

In order to be a wise healthcare consumer, they must understand their chronic disease.

The recent FDA statement about statins causing Type 2 Diabetes has been confusing to patients. Statins can be expensive. Patients will not spend the money for the statin nor adhere to a treatment plan if they think they will be harmed by the medication.

An understanding of the pathophysiology of Type 2 Diabetes and hypercholesterolemia will make it clear that there is no relationship between statin therapy and its causing diabetes.

At least 20% of the population has genetic insulin resistance. There is a slight difference between ethnic groups with the incidence being 30% in Hispanics and Native Americans.

This genetic defect results in a rising insulin level as the patient becomes obese, older and/or stressed.

The increase in childhood obesity in genetic insulin resistance children is causing an increase in childhood Type 2 Diabetes.

The underlying genetic defect can express itself before the blood sugar rises out of the “normal range.”

Insulin Resistance Syndrome has had several names over the past 30 years. One name was the Deadly Quartet. The quartet consists of obesity, hypertension, hypercholesterolemia, and diabetes.

Insulin Resistance Syndrome’s new name is Metabolic Syndrome. Each disease can present independently at different times. Hypertension, hyperlipidemia and diabetes are usually precipitated by obesity, stress or steroid therapy.

If patients understood the pathophysiology of metabolic syndrome they would try hard to lose weight and adhere to medication prescribed.

Patients must be taught to become the professor of their disease.

It is insufficient to say “doc, my cholesterol is high, fix me”. The only people who can “fix” patients with chronic diseases are patients themselves.

What do we know about Type 2 Diabetes Mellitus and insulin resistance?

1. The incidence of Clinical Type 2 Diabetes Mellitus is high in patients who are obese.

2. Clinical Type 2 Diabetes (high blood sugar) can disappear with weight loss and exercise in early onset diabetes. These patients still have insulin resistance but the resistance is decreased and the blood sugars become normal.

3. Obesity must be decreased in order to eliminate overt diabetes. If not, the medical cost of treating diabetes and its complications will continue to rise.

4. High LDL cholesterol is a frequent complication of Type 2 Diabetes.

5. High LDL levels cause coronary artery plaques. The result can be myocardial infarction (heart attack).

6. Diabetes Mellitus is frequently first discovered at the time of a myocardial infarction (heart attack). Mildly elevated blood sugars could remain asymptomatic for an average 8 years and discovered after a complication of diabetes (heart attack) occurs.

7. Treating high LDL cholesterol with statins in Type 2 Diabetics decreases the incidence of myocardial infarction.

8. Statins decrease the production of LDL in the liver by inhibiting an enzyme that produces LDL.

9. High blood sugar and high insulin levels also decrease nitric oxide levels in the lining of blood vessels (endothelium). The result is a narrowing of the coronary arteries.

10. Statins stimulate an increased endothelial nitric oxide production. Statins dilate the coronary arteries.

11. The dilatation of the coronary arteries along with the decrease in LDL production decreases plaque formation and the risk of a myocardial infarction.

12. High insulin levels in early Metabolic Syndrome inhibits LDL receptors ability in the liver to attach to circulating LDL. This inability to attach to the liver cells decreases the liver’s ability to sense there is enough cholesterol in the blood stream. The liver then increases the production of LDL.

13. Statins inhibit the liver from producing more LDL. Lowering the LDL produced decreases LDL in the blood stream.

14. Logically, by lowering LDL cholesterol production with a statin the effect of insulin resistance to increase cholesterol production is neutralized. The use of statins in Insulin Resistance Syndrome does not cause diabetes.

15. Therefore data for the FDA’s black box warning is wrong.

Education is the key to chronic disease management.

Physicians must teach patients in terms they can understand. Education will only be effective if patients are motivated to learn.

Physicians must be motivated by consumers to teach. Consumers controlling their healthcare dollars could motivate physicians to teach them at their level. Physicians could use their own social networks to provide customized instruction.

Obesity is the core-precipitating problem in Metabolic Syndrome. My ideal Medical Saving Account with its financial incentive could help change the obesity problem in America.

The ideal MSA might even compel the experts to not throw misinformation around lightly and frighten the public.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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