Rethinking Diabetes: Why Lowering Sugar Isn’t Enough for Your Health

Welcome to The Diabetes Blueprint powered by Lower The Dose™. In today’s episode, host Dr. Rangi dives deep into the evolving world of diabetes care, challenging long-held assumptions about blood sugar management. While lowering blood sugar has historically been the gold standard of diabetes treatment, modern research reveals that not all medications are created equal. Some drugs just lower the numbers, while others provide lasting protection for vital organs like the heart and kidneys.

Together with insights drawn from the upcoming book The Diabetes Blueprint, this episode unpacks the major shift from simply chasing sugar levels to a more holistic “heart first” approach. Leila and her guest clarify which medications truly defend your body and how thoughtful choices can mean fewer pills, fewer side effects, and more years of healthy living. Whether you or a loved one are managing diabetes, or you simply want to understand what modern, precision-based medicine looks like, you won’t want to miss this conversation.

00:00 Understanding Diabetes Medications

06:39 Heart safety requirements for diabetes drugs

08:13 Evaluating new cardio-protective drugs

11:15 Non steroidal MRAs for kidney health

16:55 Prioritizing organ protection

19:22 Explaining insulin necessity

23:38 Reducing diabetes medications with new drugs

25:00 Asking about medication benefits

27:40 Five protective medication shields

The Metabolic Longevity Quiz -  rangimd.com/quiz 

The Book companion site-  rangimd.com/blueprint —  (MAP checklist, downloadable tools)
 

The Upstream Diabetes Course - rangimd.com/upstream 

ADCC Provider Training- rangimd.com/academy

The Metabolic Longevity Program- rangimd.com/join —  (work with Dr. Rangi directly)

Show Website - https://lowerthedosepodcast.com/

Dr. Rangi's Website - https://rangimd.com/

Podcast Partner - TopHealth - https://tophealth.care/

Dr. Rangi's LinkedIn - https://www.linkedin.com/in/jaiwant-rangi-md-face-32226b97/

“Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”

Transcript

SPEAKER_01 0:00

I can write you two different descriptions. Both will lower your blood sugars or A1C by exactly the same amount on your lab report. They look identical. The blood tests will look great. But one of them will quietly protect your heart and your kidneys for the rest of your life. And the other just lowers the blood sugars on the numbers and walks away. Now for decades we hand it out the second time and called it good control. That era is over. And today I'm going to tell you why.

SPEAKER_00 0:59

Because there's from what we learned, there's not just one. And today, what we're going to get into a little bit more is about medications. And from what you're telling me, they're not all interchangeable, as a lot of people would assume. And even when the numbers look the same, they're not, they're quite not the same. So before we dive all the way in, I should mention a lot of what we covered today and across the entire series from the last few episodes and moving forward comes from your upcoming book, The Diabetes Blueprint, which listeners can learn more about on your website, rangemg.com backslash blueprint. And we'll remind all the listeners later again. But I did want to preface that and say that all of this is related and coming from your book. And we'll again touch base on that at the end of the episode as well. But I'm excited to dive into this.

SPEAKER_01 1:46

Yes, Leila, that's right. The book goes deeper into every one of these discussions and ideas, the stories, the science, the practical tools that we talk about. It's expected to be out sometime in mid to late July. And I wrote it for the exact people who are listening to it right now. Patients, families, caregivers, and anyone who wants to understand the modern diabetes care. Not just follow the orders. And the book is going to help anyone with diabetes, pre-diabetes, or if they just are at a high risk for diabetes, I have tons of good information and tools. So definitely I would encourage them to check it out. But today let's give them the core of it, the gist of it.

SPEAKER_00 2:35

Absolutely. And before we get to the medication and the drugs, I know you say something that tends to surprise a lot of people that diabetes is not just really a sugar disease. And that's what I think a lot of people associate diabetes with. So what do you mean by that?

SPEAKER_01 2:51

Yes, Layla. Diabetes is not a sugar disease. It is a cardiovascular kidney and a metabolic disease. So it affects your heart, it affects your kidneys, and it affects your metabolism overall. The sugar is a signal in much larger storm, okay? But it's a lot more than just sugar. It affects your heart, affects your kidneys, affects your blood vessels, affects your brain, your eyes, your nerves, feet, liver, and your future. So the American Heart Association now formally recognizes this. They call it CKM syndrome or cardiovascular kidney metabolic syndrome because these systems are so deeply connected that you cannot treat one and ignore the other one. I opened the book with a patient called that I call as Kumar. He looked healthy, exercised daily, he felt fine. A spare glucose monitor showed his glucose nearly 400. His blood pressure was 200 over 100, and his heart was already under strain. In Diabetes Blueprint, I walk through Kumar's full story and how we rebuilt his plan from a ground up, you know, from the surprise diagnosis to how we handled organ by organ and take care of him as a whole. Today I will give you the principle behind it. His blood sugar was just an alarm. His heart was the emergency.

SPEAKER_00 4:25

And I think for years the goal had been to just really lower blood sugar, but why was that not enough?

SPEAKER_01 4:31

Leila, the old model was simple. Lower the sugar at any cost and assume everything else will follow. You know, that's what we knew. Even during my training, which I finished in 2005 in Michigan, we were not so concerned about the heart being the primary organ with diabetes. We learned sometimes the hard way, and that you can drive the sugar numbers down with certain drugs and not change or even worsen a person's risk of heart attack. One large trial called the Accord trial actually had to be stopped early because pushing the sugar too aggressively down in older adults led to more deaths, not fewer. So keep getting lower and lower is not the goal in everyone. A normal A1C was never the real goal. It was stand in for what we actually want: more ears, more living with your heart, kidneys, and brain intact. The new model flips it. Ask first what protects your organs. So any medication that we want to choose has to do more than just the blood sugar. And then choose the tools that lower the sugar and defend the body at the same time. The question is no longer how low is your sugar. The question is how safe are your organs.

SPEAKER_00 5:50

And I think that this is really important, and this is the heart of the episode. I think two medications, same drop in A1C, but different outcomes. So how is that possible?

SPEAKER_01 6:01

Yeah, because lowering the sugar and protecting organs are two completely different jobs. Some medications do only the first and some do both. And I find it hard for my patients to understand that when I try to tell them that I want to use this medication instead, and they would try to not fight me, but they would try to sort of downplay because they've been on a certain medication for a long time. And they're like, why do you really need to change this? So starting around 2008, you know, like I mentioned, I finished my training in 2005. 2008, the regulators began requiring something new. Every diabetes drug had to prove it was not harming the heart. You know, it was after a meta-analysis that showed that some people were getting more heart disease, and it started showing us that we need to make sure every drug that we use for diabetes is safe for the heart. So in 2008, the regulators began requiring something very new. Every diabetes drug had to prove that it was not harming the heart. That changed everything. We started asking the drugs to prove not only they lower the blood sugar, but that they also protect the heart and the kidneys and they save lives. Some classes did that exactly, and others simply did not. And in fact, what was required earlier was to show that those drugs do not harm the heart. And then suddenly there was a trial that came out called LEDAR trial, and that was from LEDA glutide or the drug called Victosa. And what it showed was not only did it not hurt the heart, it also improved the outcomes. So suddenly we all started thinking about, huh? We're not only are not hurting, but some people who are taking certain medications are doing better. They're protecting the heart. So after that, now we are always looking into new drugs that come out of the market. They have to prove that drug that is coming out is safe, number one. And if it can be cardioprotective, then it's even better. So two patients can reach the same A1C. One walks away with a medication shown to lower the heart and the kidney risk, while the others walk away with only lower blood sugars. Same lab report and completely different future. That is the most important thing to understand about the modern diabetes care.

SPEAKER_00 8:15

Absolutely. And so in plain language, let's name them. So which medications actually protect the organs?

SPEAKER_01 8:22

Yeah. So this is going to be complex, but I'm trying to simplify it as much as possible. I'll speak in categories, and this is education, it's not a prescription for anyone. Your plan is always between you and your clinician. So don't think this is a plan for you. So two newer classes change the game. One is called GLP1 agonist or receptor agonist, and the other one is called SGLT2 inhibitors. Too many alphabets, again, like an alphabet soup, but let's say it again: GLP1 agonist and SGLT2 inhibitors, glucagon-like peptide 1 receptor agonist and sodium glucose co-transporter 2 inhibitors. The GLP1 class helps the body use its own insulin, calm the appetite, support the weight loss, and in large trials has reduced heart attacks, strokes, cardiovascular death by roughly 10 to 20%. And some of these drugs have also been shown to slow the kidney disease. Now, you have to understand not all GLP1s have shown that. The second class, SGLT2 inhibitors, can help kidney clear the excess sugar and the fluid. And in trials, these drugs have reduced the heart failure hospitalizations by 30% and slowed the kidney disease progression even in some patients who do not have diabetes at all. So that tells you the benefit goes beyond blood sugar. You know, metformin is something we've used for years and years and decades, in fact, that remains a sensible foundation for many. We still use that. It has been around for decades and it is affordable. Long-term data suggests it's likely to offer some cardiovascular protection of its own, though the evidence is not as strong as for GLP1 aginus and SGLT2 inhibitors. Now there's also a newer class worth knowing about. We call them non-steroidal mindralocorticoid receptor antagonist. For example, with people with diabetes and kidney disease who are already on the right medications, adding one of these medications has been shown to further reduce the kidney decline and the heart failure. Your clinician may bring it up if the kidney protection is a priority. Not everybody needs this. We don't use the non-steroidal mineralocorticoid receptor antagonist to lower the blood sugar, but the other SGLT2 and the GLP1 agonists also lower the blood sugar. The non-steroidal minerocorticoid receptor antagonist that we have available at this time, the only one that we have available in the United States is phenerinone, and it is called as kerandia in the market. So that is a drug that we give only if you have declining kidney function and you have protein urea or ping protein in the urine. So in the book, I lay out a simple framework, what I call as protective medication gap, that shows that these classes they work together layer by layer. And it is one of the tools that I'm most proud of in the diabetes blueprint because I've tried to clearly give that in simple language for the patients to understand. The point is not the brand names. The point is that these tools do more than lower the numbers. You need to know what medication you're taking. If that medication has shown to be safe and cardioprotective, we always prefer the versus something that just lowers the blood sugar.

SPEAKER_00 11:47

And they defend the body. And then on the other side, which ones just lower sugar and are they bad? Yeah, that's a great question.

SPEAKER_01 11:56

You know, sometimes what happens is we add somebody's blood sugar is not under control, and I end up adding one of these new classes of medications. And the patient will say, Well, I'm already taking something that is, you know, I have such big copay and I can't afford it. So I'm not going to take these new medications. I can't afford it, you know. So I have to educate them that let's stop the other medication because the other one you're paying so much copay and it's not doing any cardio protection, it's only lowering the blood sugar. So it's important to understand that. The older sulfonine ureas, that's a class of medication that we use. Those go by the names of glipizide, gliberide. They squeeze more insulin out of the tiring pancreas. So all they do is they work on your pancreas, they squeeze the pancreas to make more insulin and secrete more insulin. They lower the sugar, but they can cause low blood sugars and some weight gain. So both the things that we don't desire. And they do not carry any organ protection of newer classes. And in fact, the large comparative studies have shown that people on sulfon ureas have higher rates of cardiovascular events than those with newer cardioprotective medications. Now, older sliding scale habits like giving insulin right before eating based on the blood sugar numbers or just to add more approach fall into the same trap. You know, we don't like sliding scale. Chasing the number and not protecting the person's organs or protecting the person as a whole is not desired. Now, these drugs still have place. Cost and access are real. You know, in many parts of the world, sulfuring ureas and metformin may be the only options available, you know, because those have been available for years. And lowering dangerously high sugars still matters. You know, we don't want people to be running around with high blood sugars because it decreases your immunity. You have so many other complications, including heart disease. So we have to balance it. You know, we have to understand what is somebody's risk, what are my options? Can I use the newer medications? If I can't, I'll still use the other one to lower the blood sugars. For pancreas, that is already tiding, squeezing it harder is not a long-term plan. We also have a class of drugs called DPP4 inhibitors, and I have not mentioned much about it here, but yeah. So all those medications can really help you control the blood sugars, but organ protection has not been shown.

SPEAKER_00 14:15

So I know you also have a phrase heart first. So why does the heart come before the sugar?

SPEAKER_01 14:21

Great question, Leila. Because the heart is what most often takes people with diabetes: heart attack, stroke, heart failure. People don't die of diabetes. People die of heart attack, people die of heart problems. So because they're so interconnected, heart is the primary reason why we need to protect it. High blood sugar is going to cause the heart attack. It's not high blood sugar itself that is hurting you. So the sugar is an alarm and heart is the emergency. I write about a patient called Marcus in my book, where the whole plan was built to protect his organs first, heart first, and let the sugar follow. Marcus's story is, you know, in one of those chapters in the book that readers tell me that it hits them the hardest. Because it shows what happens when you flip the priority. When I meet a new patient, I'm not only asking them how high is the sugar, I'm also asking them, what is the risk of your heart? Have you ever had heart disease before? Where are the kidneys? Are the kidneys working okay? You know, one of the things we see is people often do not even know that they have slight decline in kidney function. So that is something we have to assess and analyze and do talk to patients about it. Then comes the brain, you know, and which tools are defending them? Are we doing things to protect those? The new guidelines recommend that use the protective medications, even if the A1C is already a target. That tells you this works above and beyond just the blood sugars. The organ protection is the reason, not just the sugar lowering. And that is a fundamental shift in diabetes care. Protect the organ and good sugar control comes along for a ride. Chase only the sugar and you can lose the organ. So we have to tie up the whole picture with the patient and use the right medication. And when I say irrespective or regardless of the A1C, what we are trying to say is when I have a patient who comes to me with an A1C of let's say 6.5, and that's my goal, and then I'd say, Well, you're doing very well, your numbers are good, but guess what? I'm going to change your medications. And they're like, Why would you do that? I'm doing so well. My blood sugars under good control. Because you're on medications that are not protecting your heart. So even though your numbers are excellent, let me switch to something that will go above and beyond the blood sugars.

SPEAKER_00 16:38

And then in all of this, where does insulin fit in? We talk about it a lot, but where does it fit? And some people fear it and some people need it. So how does that really work?

SPEAKER_01 16:48

I think, Leila, that is again one of the very important questions. So thanks for asking. Insulin is not a punishment and it's not a failure. I see a lot of patients trying to avoid it. And I often have to explain it to them that the only reason I'll give you insulin is because you absolutely need it. So in that case, there's not much room for bargaining here. You know, we're not trying to tell you that you got to take this and that's the only way we're going to treat you. So for some people like type 1 diabetes, LARA, that we talked about latent autoimmune diabetes of adults, and those with whose pancreas are running truly low and not able to make enough insulin, it is essential and life-saving. Without it, they cannot survive. So in those patients, no question, they need to be on insulin. And that's another topic for another time that the insulin that we usually give is injectable only. There's also inhaled insulin that is ultra-fast acting. And I always ask patients to encourage to talk to their doctors about it because I use inhaled insulin extensively in my practice, and it's a game changer. Not trying to overexaggerate it, but patients tell me it's a game changer. But the only thing people need to understand is it cannot replace your long-acting insulin. There are two kinds of insulins, long acting and short acting. Long acting covers you throughout the day, short acting covers you every time you eat. So short-acting insulin, inhaled insulin is a short-acting insulin. It will not replace your long acting, but it can help you take fewer injections because you don't need the injection with each meal. In that case, we can do the inhaled insulin and the long acting, you'll have only one shot. And sometimes you give insulin punk because it's in the insulin, you know, in the injectable form. So we don't have any oral formulation at this time, but inhaled insulin is the best as close to as you get. So, like I said, in type one, LARA, there's no negotiation. You gotta be on it. If your tank is empty, if your body's not making insulin, no option. You gotta go on it. Now, in that case, we're not changing the resistance, we're just replacing it. But here's what has changed for people with type 2 diabetes who need something beyond metformin, the guidelines now say that GLP1 receptor agonist is generally preferred over insulin compared to before. So GLP1 receptor, your first injection should be a GLP1 receptor agonist, not insulin, because it offers organ protection, weight loss, and lower risk of dangerous lows, because it stops working. It makes your own insulin work better. So if your blood sugars are not high, the GLP1 agonist is not going to push more insulin from your body. So the goal is never insulin for everyone, but insulin for the right people. And if the right tool for your biology, it is the right tool for your biology. At the same time, we should not use this for type 2 diabetes. So using it the right person at the right time and not too late, we have good reasons to use insulin.

SPEAKER_00 19:48

And your whole philosophy, which we've talked about in previous episodes, is cause lower the dose. And I think people might hear that as less medication is always better. But is that actually what you mean by that phrase or that philosophy? No, no, no, Leila, not at all.

SPEAKER_01 20:04

And this matters, and I'm glad you asked that question because my my goal is not to tell people take less medication, and it's not anti-medication. It is precision-based medication. It means using the right tool so well that it protected drugs and the lifestyle as a foundation. And that many people can often translate into needing less medication because we're trying to go in a very targeted manner in a precision-based fewer pills that only mass the number, fewer lows, and fewer side effects is my goal. Sometimes lowering the dose means adding one protective medication and removing two bad ones. We're just chasing the sugar. The American Diabetes Association usually it's actually says that when you start protective drug, you may need to reduce or stop the medications to avoid low blood sugars or unnecessary complexity. So it's not just me, even ADA says that. And let me give you an example. When you start a GLP1 agonist, you need less outside insulin because you're making your own insulin work better. And I've had many patients that I've taken off of insulin. Not just me, even other doctors. So GLP1 agonist, it works so well on your body that it helps you not need so many more medications. So you automatically are going on lower medication numbers and doses. And same thing with SGLT2 inhibitors. That makes you pee more sugar, and the way it works, it also helps you need less of other medications. So this is a philosophy that runs through the entire book and every chapter comes back to it. It is not less of just for the sake of less medications, it is least medication that is needed to give you the most protection. I hope that answers this.

SPEAKER_00 21:48

Absolutely. And before we wrap up this episode, if they're someone who's gonna see their doctor soon, what should someone really ask at their next appointment? One question to watch for the next visit.

SPEAKER_01 22:00

The patient should ask for is does the medication only lower my blood sugar or does it also protect my heart and kidneys? That's the only thing I want them to ask. And then they can ask, Am I the candidate for the newer class? You know, if they're not on it, am I the candidate for the lower class of drugs that lower that not only lower the blood sugar, they also help me protect my heart and my kidneys? And if not, why not? You know, and sometimes I question myself when I see these patients and I'll say, Well, why did I not have you on that medication? And then I learned that we tried and it was either the side effects or the cost or some reason was there or something or the insurance didn't cover and you know, cost prohibitive, things like that. So you need to understand why I am not on the standard of care or the state-of-the-art care, which is the medication that protect your organs. And is anything on my list only chasing the numbers? You know, could anything be simplified? Could we modify the treatment? Do not stop or change anything on your own. You need to make sure that you talk to your clinician. Bring your medications and your questions to each visit. And if you want these questions written out, ready to hand out over to your doctor, we'd love to get those kind of questions. And you could even take the book with you and try to understand how that relates to your care. The right questions are how you get the right medication in your hand.

SPEAKER_00 23:18

Absolutely. I think that this just really reframes the entire pharmacy aisle for me, for sure.

SPEAKER_01 23:24

Yeah, well, Leila, one of the things that I talk about in my book is also, you know, I've given a tool for patients to think about your medications as three classes of medications, you know, one is uh shield, you know, there are five shields I talk about. And then there's number two is protection, and number three is release. Okay, because we see so much polypharmacy or people out unnecessary too many medications and supplements that they should not be taking. It's a good idea to take all your medications to your doctor and ask them to help you sort it out and tell me what is the class of medications that are protecting my body? What are the class of drugs that I should take to help support them if I need to take it? And what are the ones we can release? Let go. We don't need them anymore, you know, and be on the most important medications. And there are five shields that I talk about in my book. And those five shields are there are two that we've been using for years and years. Those are ACE inhibitors and statins or cholesterol-oring medications. There are some people who cannot take statins, so then we can use alternative medications, but they have been shown to be protective for you. Now, in addition to those two, the other two are GLP1 and STLT2 inhibitors that are cardioprotective, not just any GLP1 and not just any STLT2 inhibitor. And the last drug that I talk about, the fifth shield that I talk about, is phenerinone or carendia, that is the mineral-corticoid receptor blocker that we talked about. But that is not for all comers, that is only for people who have kidney insufficiency and they need or they have proteinua. So yeah, talk to your doctor, ask them for those five shields, read the book, and you will be good for future.

SPEAKER_00 25:03

Absolutely. And for anyone who really wants to go deeper, the patient stories, the frameworks, the philosophy, the practical tools, I know your book covers all of that. And I know it's coming out soon, the diabetes blueprint. Remind us when it's coming out again. Mid-July to late July.

SPEAKER_01 25:18

And we'll be offering membership as well where people can be in a group learning where we're going to be talking more about the book on a regular basis.

SPEAKER_00 25:27

And I know that this is written for your patients, for the spouse, the parent, the adult child trying to help. And it is this book that I really wish that every patient can really have in their hand when they walk into a clinic. So thank you so much. And for everyone who wants to learn more about it, remind us the correct website where they can find it.

SPEAKER_01 25:44

R-A-N-G-I-M D.com, rangiemd.com slash blueprint.

SPEAKER_00 25:51

Absolutely. Thank you so much. This is always a pleasure to speak with you. I always I know I always feel like I learned so much, and I know our patients listening are really absorbing so much information. And I can't wait for your book to come out and to continue this conversation. And I'll talk to you soon. Sounds good. Thank you, Leila. Good to see you always.