Wednesday, October 1, 2014

The Nutrition Debate #249: Type 2 Diabetics: You Have a Choice.

If you have been diagnosed a type 2 diabetic, your doctor (YOU actually) have a choice of long-term treatment options: 1) insulin injections, 2) oral antidiabetic medications, or 3) major dietary changes. I’ve oversimplified it, but this is an overview so the unschooled reader can see the “big picture.” Besides, I’m not without my own biases, as you’ll see.

To illustrate the insulin route, I cite a rather pedantic article, originally published in 2011 in Diabetes in Control, a source which bills itself as “News and Information for Medical Professionals.” It was re-posted on September 11, 2014, to promote the Humumin R insulin product. Why do I say that? From the advertising. The article is accompanied by ads for Eli Lilly and Company’s Humulin R,* as you scroll down the screen, 5 of them: top (1), side (3) and bottom (1). In fact, a hyperlink under the title reads, “Humulin Insulin Special Edition September 2014.” Maybe the whole article is just a paid advertisement.                                  * Specifically the U-500 version, a concentrated form for insulin-resistant patients requiring more than 200 units a day.

I have nothing against injecting insulin. Insulin is a good thing, and it works. And I have nothing against advertising. I do have a problem, however, when advertising and clinical practice advice get mixed together. I have an even bigger problem when the first two authors of the piece just happen to be Editor-in-Chief and Publisher, respectively, of the Diabetes in Control “newsletter.”  I didn’t know that, however, because it is revealed in the “disclosures,” as it is in a peer-reviewed medical journal. There are no disclosures. I knew it because I have been reading this “information source for medical professionals” for years.

But if you didn’t know, and care to go to the trouble, Google David Joffe (the Diabetes in Control Editor-in-Chief), and learn, “Dave speaks on diabetes, hypertension, and related co-morbidities for Abbott, Bayer, Pfizer, Novo Nordisk, Lilly, Sanofi, Sankyo, and Medtronic” (emphasis added). Or, “Dave is a non-physician member of the Lilly Primary Care Diabetes Advisory Board.” Admittedly, conflicts aside, reading his full curriculum vitae, the guy has mega bona fides.

Nevertheless, the “Practice Pearls” for insulin as a treatment for newly diagnosed Type 2s are a good “takeaway”:

     By removing the glucolipotoxicity you can improve beta cell function.

     Since Type 2 diabetes is a progressive disease and will worsen over time, by improving beta cell function the progression of diabetes can be slowed down to prevent complications

The 2nd long-term treatment option is also pharmacotherapy. Oral antidiabetic medications have evolved from the early days when insulin-secreting sulfonylureas were the only option. Today most newly diagnosed type 2 diabetics and even “pre-diabetics” (those that can “tolerate” it) are started on metformin. The dose is quickly increased (“titrated”) until you are “maxed out” and then a second agent, and even a third med is added to the “cocktail.” Since, as we’ve seen above (in the 2nd bullet), the “perceived wisdom” is that “type 2 diabetes is a progressive disease and will worsen over time,” the assumption is that many type 2 diabetics who are treated with orals will “progress” to insulin dependency.

The major downside to injecting insulin is hypoglycemia, or low blood sugar. It can lead to coma and death. That is because you, the patient, has to decide on the amount to inject before each meal or snack.  Your care giver can help on the amount of “basal” insulin you inject once or twice a day, but only you can decide how much to inject before each meal ‘cause your doctor is not at your side 24/7. Even if you have a pump and continuous glucose monitoring (CGM), which few do, you have to figure the dose of mealtime insulin that you inject each time. As a result, many patients, and their caregivers including clinicians and CDEs, do not try for “tight glucose control.” They inject too little to avoid the danger of hypoglycemia.

The exception to this would be the pioneer on glucose meters, glucose monitoring, and low-dose insulin regimens, Dr. Richard K. Bernstein. His book, Diabetes Solution, is an authoritative source for all diabetics. And Dr. Bernstein’s Diabetes Forum (registration required), accessed from the same link, is a great place for learning about all aspects of diabetes.

The downside for oral antidiabetic medications is 1) all drugs have side effects and 2) if you do nothing else and just let your doctor monitor and treat your worsening glucose metabolism, your type 2 diabetes will “progress” and “worsen over time.” And if the progression of the disease cannot be slowed down, you run the risk of developing “the dreaded complications,” not to mention macrovascular complications like heart disease.
Now, the 3rd long-term treatment option for type 2 diabetes or pre-diabetes: major dietary changes. Pros: no insulin (and no hypos), few if any oral meds (and no side effects from same), and greatly improved (not worsening) glucose control, plus a bonus: improved BP and blood lipids (higher HDL, lower triglycerides, stable Total Cholesterol and LDL). Less of that nasty MG (see The Nutrition Debate #246 here) stuff too. And another under recognized benefit: you will lose weight, have lots of energy and feel great! Cons: you have to give up the processed foods and carbohydrate-loaded junk that made you sick in the first place. It’s your choice. And yours alone.


  1. I had a totally different interpretation of the article. Having diligently followed Berstein since 2006 my A1c continued to rise towards 7% despite multiple triple medication regimes. I was systematically denied insulin for over two years. I finally took the matter into my own hands and bought insulin at Walmart. Why should a T2 patient have to wait until their blood sugar becomes demonstrably uncontrolled before being given access to insulin. In addition other studies have shown improved outcomes when newly diagnosed T2 patients are started with insulin right away to normalize their blood sugars even though they are able to shortly stop insulin.

    I don't disagree that diet is very important, but there are many patients who are being denied their right to normalize the blood sugars because they are not being given access to insulin.

    your friend bsc over at Bernstein

    1. All very good points, Brian. Your experience, totally different from mine, illustrates that YMMV (see #103, a very poplar post). Your T2DM, if effect, did not respond to diet, since your "dilligently followed Bernstein" yet saw your condition worsen despite a triple medicine regimen. That is indeed extraordinary.

      But your main point -- that you could not get access to insulin throught the medical establishment, with reimbursement -- until your disease had progressed to being "demonstrably uncontrolled" is a gross injustice and needs to be reformed.

      I agree that primary treatement with insulin for patients newly diagnosed with gross diabetes is an effective treatment modality, and that it can result in them being able to shortly stop insulin, as you say.

      As I say, I am not opposed to the use of insulin (although I admit it may seem like it from a reading of this post). I want to stress that the patient has a choice, and for most diagnosed with prediabetes to continue to eat a "balanced" diet will lead progressively to worsening diabetes and for many to insulin dependency. In my opinion, in most cases, this is an unnecessary course of the disease, and is due in large part to the complacency of the patient. That, obviously, is not the case with you, and I give you all credit for taking the bull by the horns and getting your insulin at Wallmart, on your own hook, unfortunately.

    2. This post, (#103) has had over 1k page views:

    3. Dan,

      I think we are in violent agreement about diet. My diabetes did respond to diet. My blood sugar drop from going low carb was far far greater than I could have ever hoped to achieve from T2 medications. I just have a different read on the background of the diabetesincontrol article. In 2009 or so there was a resurgence of debate about early insulin use (see ). The standard treatment algorithm used insulin as a last defense and it is even called the "step-wise" algorithm. Insulin was the absolute last step. But starting in 2009 there was change in the wind. This article reflects that. Subsequent changes in the algorithm started to include insulin as an earlier alternative treatment mode. And today we are seeing lots more evidence that we get better outcomes when we normalize blood sugars and early insulin does that (see Origin trial results ).

      I remain convinced that I did the right thing starting insulin. And I totally agree that dosing ever increasing amounts of insulin to compensate for a ludicrous high carb diet is crazy, I don't think the authors of the diabetesincontrol had that on their agenda.


    4. Your read on the diabetes-in-control article is correct. I could have and should have chosen a different link, but this one irked me as much for the fact that it was recycled and basically was an advertisement for a concentrated form of insulin.

      I don't doubt for a moment that you made the right decision, and I support it (for what that's worth). Insulin as a primary intervention to normalize blood sugars and preserve pancreatic beta cell function is a very good treatment modality, especially for newly diagnosed patients with frank type 2 diabetes.

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